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SAN JOAQUIN COUNTY _ SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AGRICULTURAL HAZARDOUS OFFICE OF THE <br /> 600 E MAIN ST - AGRICULTURAL COMMISSIONER <br /> STOCKTON,CA 95202-3029 MATERIALS INVENTORY 2101 E.Emhart Ave.,Suite 100 <br /> PHONE(209)468-3420 STOCKTON,CA 95206 <br /> PHONE(209)953-6000 <br /> Part L• General Information <br /> Business,Farm or Ranch Name: Site Locations/Address(include zip code): Phone No: <br /> ► Rvw o J, I L a apict q791313 <br /> Mailing ddress(if different fromove Description of Busin s/Operation(Farm,Nursery,Etc.): _ Nearest Crossroad: <br /> 3s I Qv• q9 F Qr LlQlri R <br /> Emergency C ntact Person: Phone No: Pesticide Permit/ID No: Fire District: <br /> J� q 4$a r bQl*ln� <br /> Part II:Hazardous Material Information Refer to the Agricultural Hazard Material Worksheet for the materials that should be listed below and their reportablequantities) <br /> Material Name DOT# Container Container Sin Max.Number Circle the Months On Site Locations(s)on the property(e.g.in barn,NW <br /> C"' Type of Containers corner of property) <br /> M <br /> �..1 at any I time <br /> FMAMJJASOND E <br /> 'op, iaoonk. JFMAMJJASOND <br /> !aI O <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND c§ CLg7 <br /> DEC 241. JFMAMJJASOND <br /> qAN OA001 '_;DU lTY JFMAMJJASOND <br /> GRiC. CON M. LUUI <br /> JFMAMJJASOND <br /> AGRIC. COMM. LODI <br /> JFMAMJJASOND RECEIVED <br /> JFMAMJJASOND JAN <br /> I cert�ify�that the above hazardous material information ij true and correct to the best of my knowledge. pif, - � <br /> AGR <br /> t l��(1 1 �{ - I Additional Inventory Sltee sqg <br /> hed: <br /> Signature Name(please print) Date Yes❑ No <br /> (Return completed form(s) to the San Joaquin County Agricultural Commissioner. Do not submit fees with inventory. Fee pay nt will be <br /> collected based on invoicing by the Environmental Health Dept.) (rev. 10/I5/08) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br />