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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 loo <br /> PHONE(209)468-3420 STOCKTON,CA 95206 <br /> PHONE(209)953-6000 <br /> Part I: General Information <br /> Business,Farm or Ranch Name: Site Locations/Address(include zip code): Phone No: <br /> w ► m r Lv, �Iwylq LOIL, a Q0Q q23j5SS16 <br /> Mailing A dress(if different from above: Description of Business/Operon(Farm,Nursery,Etc.): Nearest Crossroad: <br /> Emergency Contact Person: Phone No: Pestici a Permit/ID No: Fire District: <br /> aoet �t-7� ► 1 3;-11- Q04aa,7 — WOvdbri �e. <br /> Part If: Hazardous Material Information Refer to the Agricultural Hazard Material Worksheet for the materials that should be listed below and their repo tablequantities) <br /> Material Name DOT# Container Container Size Max.Number Circle the Months On Site Locations(s)on the property(e.g.in barn,NW <br /> Type of Containers corner of property) <br /> at any I time <br /> iqnKJFMAMJJASOND ni <br /> Gas It o— 11600 <br /> FMAMJJASON �� '`o_ <br /> JF*4AMJJAS0ND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND RECEIVED <br /> JFMAMJJASOND JAN 11 2011 <br /> I certify that the above hazardous material information is true and correct to the best of my knowledge. <br /> MI-_ \1 � M '_ p AGR. COMM. - STOCKTON <br /> -,G�t►�l . 1 t I� Q�� �•II Additional Inventory Sheets Attached: <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 payment will be <br /> collected based on invoicing by the Environmental Health Dept.) (rev. 10/15/08) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br />