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SAN JOAQUIN COUNTY SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AGRICULTURAL HAZARDOUS <br /> CEIt1819 <br /> D OFFICE OF THE <br /> 600 E MAIN ST AGRICULTURAL COMMISSIONER <br /> STOCKTON,CA 95202-3029 MATERIALS INVENTORY Fp 2101 E.Earhart Ave.,Suite 100 <br /> E <br /> PHONE(209)468-3420 DD 6 STOCKTON,CA 95206 <br /> PHONE(209)953-6000 <br /> Part I:General Information �`f� 0FFIOSANJO4-rq COUNiY <br /> Business,Farm or Ranch Name: Site Locations/Address(include zip code): SERVICES Phone No: <br /> 1z�rn,s t�96 U). u� 1a-. ocL � �1� h off' 4?3 jsgId <br /> Mailing Add+s(if different from above): Description of Business/O ration(Farm,Nursery,Etc.): Nearest Crossroad: <br /> P. 0 . Bok 4101 Foc Q) ar R� <br /> Emergency Contact Person: Phone No: Pesticide Permit/ID No: Fire District: <br /> rY1;1 Ste , �� n4 q7a. X31 1'3Yt 4a "7 <br /> Part II: Hazardous Material Information Refer to the Agricultural Hazard Material Worksheet for the materials that should be listed below and their reportable uantities <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 /> i e ✓� �99 A� �� OQ JFMAMJJA,OND 14) <br /> FMAMJJASON D - <br /> i <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> JFMAMJJASOND <br /> ❑ I certi y that the aboy azardous material information is true and correct to the best of my knowledge. <br /> 1 1 <br /> CLe I"�i ,J e� � JC.t t- 2)='1- aq Additional Inventory Sheets Attached: <br /> Signature .-...-,,.case print) Date Yes❑ No[-] <br /> (Return completed form(s) to the San Joaquin County Agricultural Commissioner. Do not submit fees with inventory.Fg@�iyment will be <br /> collected based on invoicing by the Environmental Health Dept.) RRtt((�j (rev. 10115/08) <br /> KEEP GOLDENROD FOR YOUR RECORDS <br /> FEB 0 3 2009 <br /> AGR.COMM,-STOCKTON <br />