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.. .. <br /> oPqu!N C COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALDI-BALDWIN <br /> r' ROOM 610,COURTHOUSE DIRECTOR OF <br /> r: <br /> 222 EAST WEBER AVENUE EMERGENCY OPERATIONS <br /> • c�..,. ..:;P• <br /> STOCKTON,CALIFORNIA 95202 <br /> cicdA� TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> CARBON DIOXIDE DISCLOSURE SURVEY <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. <br /> Business Name C,Al�ls S✓z. <br /> Business Owner(s)Namew0ynae TeyA 0AI« JQ Telephontao�t <br /> Business Address 3aOro J4Ctm(►ye L.CAi�,1,�- - c/0�-'�(1PU 1 a5��p. <br /> Mailing Address(if different from above) � �T I`CJ� �'` /P��( � ell l, ��`��4.5t e <br /> Nature of Business 2sur2 n 1 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. 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: y ` ,t <br /> bbA Date 2>J4-/04 <br /> Print Name �t,t <br /> X _._ Title flti Ir l�t1u °� <br /> Signature <br /> (5/99) <br />