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ay.lH COUNTY OF SAN JOAQUIN <br /> �o �o <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWM <br /> ROOM 610,COURTHOUSE <br /> COORDINATOR <br /> 222 EAST WEBER AVENUE _ <br /> • i.., a STOCKTON,CALIFORNIA 95202 M R f <br /> �<rc°aa <br /> TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 <br /> { <br /> NOV <br /> - 41M <br /> tI J <br /> CARBON DIOXIDE DISCLOSURE SURVEY SAN JOA COUNTY <br /> OFFICE OF EMERGENCY SERVICES <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 Taco Bell/OCAT, INC. <br /> Business Owner(s)Name n J., AllenL Beebe �� C Telephone 209-529-6802 <br /> Business Address �'11`ful <br /> Mailing Address(if different from above) 5Y <br /> Nature of Business Mexican Fast Food Fire District f <br /> QI. YJ 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: �,p ���pp (y <br /> X kL)0I FE7` AJC e— Date <br /> Print Name <br /> X Title <br /> Signature <br /> (9/98) <br />