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pq��H COUNTY OF SAN JOAQUIN <br /> r; c OFFICE OF EMERGENCY SERVICES P.' .� RONALD E.BALDWIN <br /> e .� ROOM 610,COURTHOUSE ~ Zoeao(NATOR <br /> 222 EAST WEBER AVENUE i h <br /> c P STOCKTON,CALIFORNIA 95202 %J/ <br /> 9ciF°a' TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 4*116 <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 Owner(s)Name Aixu ya d(-o Telephone 510 q4-T-107-S' <br /> Business Address 346 7,C C edQT 4�I JJ, 6t ,* 1601 '"ower-rK/ CA (qT S 6 o <br /> Mailing Address(if different from above) p <br /> Nature of Business �'q6+ fiboC Fire District <br /> Q 1. AYes ❑ No Does your business handle Carbon Dioxide(CO2)in any quantity at any one time during the year? <br /> Q2. ❑ Yes kNo 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: ry <br /> X J 1 V \� I Date <br /> Print Name <br /> X Title <br /> Signature <br /> (9/98) <br />