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orQ.u,N c COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> c ;�• STOCKTON,CALIFORNIA 95202 _ <br /> d�iFo�N TELEPHONE(209)468-3962 1 t <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> OCT 2 31998 <br /> CARBON DIOXIDE DISCLOSURE SURVEY Lr - <br /> SAN JO 4u'd CeuiJTY <br /> 6 -OFFICEOF E^IFRGFPiCY SFRVIGES <br /> Please read the information on the reverse side before completing this survey form. A separate survey for each business name <br /> and/or address in San Joaquin County is req ired., <br /> Business Name Ct -0, 1 TJ <br /> Business Owner(s)Name WC7 vlL LPTel h e <br /> 0 Business Address I + ��" <br /> Mailing Address(if differen oma)ove) � ' Ll� N <br /> Nature of Business Fire District <br /> Ql. [ Yes ❑ No Does your business handle Carbon Dioxide(CO2)in any quantity at any one time during the year? <br /> Q2. KYes -L, No Does your business handle Carbon Dioxide(CO2)in a quantity equal to or greater than 1,200 cubic feet <br /> or 137 pounds at any one time during the year? <br /> I have read the information on this form and understand my requirements under Chapter 6.95 of the California Health and Safety <br /> Code. I understand that if I own a facility or property that is used by tenants, that it is my responsibility to notify the tenants of <br /> the requirements which must be met prior to issuance of a Certificate of Occupancy or beginning of operations. I declare under the <br /> penalty of perjury that the information provided on this disclosure survey is true and accurate to the best of my knowledge. <br /> Owner or thorized Agent: gg <br /> X \ Date <br /> Print N km <br /> e <br /> i <br /> X , Title <br /> Sig ature ` <br /> (9/98) <br />