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SAN JOAQUIN COUNTY <br /> $ ENVIRONMENTAL HEALTH DEPARTMENT <br /> N 600 East Main Street Stockton • CA 95202-3029 <br /> (209)468-3420 •Fax:(209)464-0138 • Web:www.sieov.ors/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHAR ilLnm <br /> A. EMERGENCY LEVEL 1XII u 111 EHD LOG# - d <br /> B. SOURCE OF INFORMATION <br /> NAME: s c PHONE: <br /> COMPANY: C CD{0 Em 1/ CITY: Oct kJ" g6�0 <br /> ADDRESS: r.f.dt <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: Jtvaj. CITY 5'�-oCktpr- Incorporated <br /> Bm Phytm cwripfion __7 <br /> lUnincorporated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: TIME: <br /> TIME: <br /> D. RESPONSIBLE PERSON/BUSINESS / 1 <br /> NAMEOFBUSINESS: 74 4b OCtIM <br /> CONTACT PERSON: PHONE: <br /> PHYSICAL ADDRESS: //// 1 l <br /> MAILING ADDRESS: YL..W Al. e e ZMA,CO gm. pG ACIP CA. RS-2-6L- / <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: ��+ <br /> VOLUME: <br /> CHEMICALS:. h (/�vr.- „ry a-' k r'tj trc.p� <br /> CIRCUMSTANCES: CCS (. <br /> F. ACTION TAKEN p <br /> SITE DISPOSITION <br /> A 6U C Le—Wa c!T <br />