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rq�tN COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALDE.BALDWIN <br /> ROOM 610,COURTHOUSE <br /> COORDINATOR <br /> _ 222 EAST WEBER AVENUE <br /> ` c... ��• STOCKTON, CALIFORNIA 95202 <br /> TELEPHONE(209)468-3962 M <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> OCT 2 31998 <br /> CARBON DIOXIDE DISCLOSURE SURVEY <br /> SAN JoAllUIN COUNTY <br /> OFFICE OF EMERGE?1CY SERVICES` J <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 �Joaqtn County is wired. <br /> CA 4 <br /> Business Name <br /> u iRes Owner(s)Na-' M Telephone <br /> Bus' es'"s A dre1CIS J� <br /> AQ44ag-44dF"s(i?diff, ent f om above) <br /> Nature of Business 04%tin�-` Fire District <br /> Q1. "` 'es LONo Does your business handle Carbon Dioxide(CO2)in any quantity at any one time during the year? <br /> Q2. E' 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 A orized Agent: / <br /> X Date <br /> Print Name _ <br /> X Signae Title <br /> t <br /> (9/98) <br />