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�¢"4a" • SAN JOAQUIN COUNTY 03P <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420•Fax:(209)464-3433• Web:www.siaov.ora/ehd <br /> FOS <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL © 1 ❑ II O ill I EHD LOG# <br /> B. SOURCE OF INFORMATION <br /> NAME: ft- PHONE w-3 q6K-Z <br /> COMPANY: San Joaquin County Environmental Health Department CITY, Stockton <br /> ADDRESS: 1868 E. Hazelton Ave. <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: San Joaquin County Environmental Health Department <br /> ADDRESS: 1868 E. Hazelton Ave.,Stockton,CA 95205-6232 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: ?2. 35 ,�'MfkIYA� /�� Inco orated <br /> Best Ptrysical r "" � CITY <br /> Desai tion I I ❑ Unincorporated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: „C1 TIME: T53 0 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: <br /> CONTACT PERSON: civ, , n PHONE: 209 93z- 00 <br /> PHYSICAL ADDRESS: `; l— p <br /> MAILING ADDRESS: <br /> E. DESCRIPTION ff <br /> TYPE OF DISCHARGE: �)� i -Yar <br /> VOLUME: t� <br /> CHEMICALS: 1 /n� )) <br /> CIRCUMSTANCES: 6/NG(a( '1 /�� c"S11 .Cr"V,__ 'r! .-sr61R- arT <br /> F. ACTION TAKEN J <br /> c leP• �, �-r a,7 "-ws cb"�.Q 40 Vey" <br /> SITE DISPOSITION <br /> Revised 04/19/12 Page 1 of 2 NOTIFICATION OF HAZ WASTE DISCHARGE <br />