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R4gIN COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES <br /> r' := RONALD E.6ALDWIN <br /> ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> •:�� La+ f STOCKTON,CALIFORNIA 95202 <br /> TELEPHONE(209)468-3962 D' L5 IQ ' i <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 -- <br /> OCT 2 11998 <br /> CARBON DIOXIDE DISCLOSURE SURVEY L - <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 required. q <br /> Business Name mco )eil / k-Tc <br /> Business Owner(s)Name (2)c;S co, NeA Telephoned 9^ <br /> Business Address I �' _I� g'8' L-Oe lec�gr a. CA 93,1 <br /> Mailing Address(if different from above) <br /> Nature of Business 7:F <br /> (J� cln Fire District <br /> ►vio�4C-ru,mn�e �� <br /> Ql. Yes ❑ No Does your business handle Carbon Dioxide(CO2)in any quantity at any one time during the year? <br /> Q2. Yes ❑ 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 Authorized Agent: I <br /> X �\ PAI f �cJe-,n � Date /d /_g-/9s— <br /> ame <br /> X Title _ ,• 1 <br /> Signature <br /> (9/98) <br />