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1 <br /> SAN JoAQunv COUNTY a <br /> ENVIRONMENTAL HEALTH DEPARTMENT D- <br /> `� <br /> .600 East Main Street Stockton■CA 95202-3029 114/V <br /> (209)468-3420-Fax:(209)464-0138- W(209) www.sisov.or¢/ehd <br /> (CPY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> OO <br /> A. EMERGENCY LEVEL EHD LOG# <br /> B. SOURCE OF INFORMATION <br /> NAME: <br /> PHONE: <br /> COMPANY: {,I Com' <br /> ADDRESS: r i`') <br /> DESIGNATED EMPLOYEE NAME: f PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: "f r <br /> C. LOCATION AND DATE OF DISCHARGE ,r} r / <br /> LOCATION: {t .�-� � z f„v�d koAd arY (Gill/ GM X' Inco rated <br /> a«,pny*d t b + !V�"'i[.� / Unin rated <br /> DATE OF DISCHARGE: l S 1 I <br /> DATE NOTIFFWD. 7- If TIME: S ' 06 <br /> D. RESPONSIBLE PERSONIBUSWFSS <br /> NAME OF BUSINESS: T IZ S . 7 <br /> CONTACT PERSON: PHONE: <br /> PHYSICAL ADDRESS: l aM <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: A <br /> CHEMICALS: s s <br /> CIRCUMSTANCES: Q re. <br /> F. ACTION TAKEN <br /> GT r„A � 1) r- eoVa&yw <br /> � , Cy <br /> SITE DISPOSITION <br /> ER RECORD MODIFIED Revised 05/01/2007 <br />