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U.N <br /> SALT JOAQUIN COUNTY <br /> fIRONMENTAL HEALTH DEPART-._ANT 1 <br /> 304 East Weber Avenue, 3"Floor, Stockton, CA 95202-2708 <br /> Rt (209)468-3420-Fax:(209)464-0138 - Web:www.co.san-joqquiD.ca.0 /.b �0 U <br /> ciR r <br /> . ` N <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHA;`RG <br /> California Health & Safety Code, Section 25180.E a <br /> EHD LOG #:A. EMERGENCY LEVEU: I) H III <br /> U/ (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: C r-'(i� Phone: <br /> Company: r X trzl <br /> Address: City: Zip Code: <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: City: Zip Code: <br /> C. LOCATION AND DATE OF DISCHARGE e� <br /> Location: LSD tl! ! oros A c rI • / C A-. / City dCoun <br /> (/Best Physical Description) / (Cir e On / <br /> Date of Discharge: 1 f7/ 3 ( 6 g Date Notified: D Time: rki�) P.M. <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: J�t n 4, 1 4 A <br /> Contact Person: 6Cly-. Phone: c, <br /> � alb) <br /> Physical Address: U C"2& �# �!- r City. v✓ Dc r ti✓+ Zip Code: G"1(__ <br /> Mailing Address: P,0 ; D City: I`J S 19'a Zip Code: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: A-RAY" G El <br /> Chemicals: b`i a-seL (-Ug- L <br /> Circumstances: yt-U LV 040 f Ly kf� � 6VQ/'(i ll <br /> b>C-S%_ A'tO L_l l o f 'V_11 <br /> F. ACTION TAKEN <br /> Q <br /> Nr L �r 3 <br /> SITE DISPOSITION- Ca� vii tE�!C-'l ��;��4�. �� t✓t i F'P� r C_ <br /> 6 y f� 5 /j <br /> if y Lr •l/V' f ( 9 C 11,.,�-a. F f fes. �.� ' i Y , <br /> f <br /> EHD 22-02-003 Notification of Haz Discharge <br /> 10/2/2003 <br />