Laserfiche WebLink
�ay.1H COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD R.BALDWIN <br /> ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> • r... `P., STOCKTON,CALIFORNIA 95202 <br /> 'Clco'M1N (� ('� (� 2 <br /> TELEPHONE(209)468-3962 ,�t i L5 lH Lr, <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 I? '•, ��`�`- <br /> OCT - 21M <br /> CARBON DIOXIDE DISCLOSURE SURVEY y <br /> �(110A7, <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. I C 60— <br /> Business Owner(s)Name J. Allen Beebe Telephone 209-529-6802 <br /> Business Address 801 10th St. , 5th Floor, Ste 112, Modesto, CA 95354 <br /> Mailing Address(if different from above) <br /> Nature of Business Mexican Fast Food 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. I/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: \` 1 <br /> eW <br /> YAJgC Date <br /> Print Name <br /> X— Title <br /> Signature <br /> (9/98) <br />