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Wr - 71999 <br /> COUNTY OF SAN JOAQUIN �-yk , <br /> OFFICE OF EMERGENCY SERVICES RW 't�""ang__ - <br /> Qy-+ ROOM 610,COURTHOUSE COORDINATOR <br /> w. : < <br /> 222 EAST WEBER AVENUE <br /> STOCKTON,CALIFORNIA 95202 <br /> r�Ppw� 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 <br /> isrequired:--- <br /> Business NameY �(� � ✓�� � � ��yj / O-� CL// U�(� \ 2 2 y' <br /> Business Owner(s)Name /`lam-� �1YnUE� /T,SSC�Ci I Amt-)-e�.,�.S TelephoneLZO l - J67 <br /> Business Address (J �� �/- f✓1fl _ , 1 (JI �L T�w ( 71J <br /> Mailing Address(if different from above) C 2 l �- 0 �� r�� J U r le i ) �s/ cf, <br /> Nature of Business "�, �"/>2'06"�T Fire District U <br /> QI. xYes 1❑ No Does your business handle Carbon Dioxide(CO2)in any quantity at any one time during the year? <br /> Q2. 0 YesyG No Does your business handle Carbon Dioxide(CO2)in a quantity equal to or greater than 1,200 cubic feet <br /> X 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 Occupancyor beginning of operations. I declareunder 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 M I C'L L d �� +f t 1, Date ! v / G ` 0 <br /> Print Name <br /> A ����� <br /> X ��� R Title /'' - <br /> Signature <br /> (9/98) <br /> 7 <br /> .; F <br />