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pqurN COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALDI-BALDWIN <br /> r.� <br /> `a ROOM 610,COURTHOUSE COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> r�... STOCKTON,CALIFORNIA 95202 <br /> BIRO TELEPHONE(209)468-3962 <br /> i HAZARDOUS MATERIALS DIVISION(209)468-3969 ' 11 <br /> v <br /> CARBON DIOXIDE DISCLOSURE SURVEY SAN JO <br /> AApp <br /> jLN COUNTY <br /> OFFIUIN COUNTY <br /> CES OF EMMMi C 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 <br /> Business Owner(s)�7NameY1 \ �� �� "{ �GO\� Telephone <br /> � 1(����a\�, t� <br /> Business Address Cl�� W \� '�'� 4-�� lilt ll� " <br /> Mailing Address(if different <br /> from above) <br /> Nature of Business Fire District <br /> Q1. VYes No Does your business handle Carbon Dioxide(CO,) in any quantity at any one time during the year? <br /> Q2. Yes 5"No Does your business handle Carbon Dioxide(CO,)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: <br /> X � "" \ \ ` bv 1\" ' � Date <br /> Print Name <br /> X ��r� Titley\nGl1L� <br /> Signature <br /> (9/98) <br />