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r I <br /> COUNTY OF SAN JOAQUIN <br /> OFFICE OF EMERGENCY SERVICES RONALD E.BALDWIN <br /> ROOM 610,COURTHOUSE <br /> COORDINATOR <br /> 222 EAST WEBER AVENUE <br /> ..• �� STOCKTON,CALIFORNIA 952027," <br /> TELEPHONE(209)468-3962 <br /> HAZARDOUS MATERIALS DIVISION(209)468-3969 OCT 2 3 @0UR <br /> CARBON DIOXIDE DISCLOSURE SURVEY <br /> Please read the inform 'on on the reverse side before completing this survey form. A separate survey for each business name <br /> and/or address in S JaquCounly is 'red. <br /> i <br /> Business Name n �� <br /> Business Owner(s)Nam �'� le one 14 <br /> ✓ <br /> Business Address 1 " <br /> Ilk y1 � <br /> Mailing Address(if differe fro above <br /> S J <br /> Nature of Business �' Fire District <br /> Q1.11- Yes <br /> No Does your business handle Carbon Dioxide(CO2)in any quantity at any one time during the year? <br /> Q2. ❑ No Does your business handle Carbon Dioxide(CO2)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 Date <br /> Print dame <br /> X Title ' <br /> Sig ature <br /> (9/98) <br />