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IQ.Pau 1'V SAN JOAQUIN COUNTY i <br /> ? ENVIRONMENTAL HEALTH DEPARTMENT <br /> U yam:{ 1868 E. Hazelton Ave., Stockton•CA 95205 <br /> (209)468-3420•Fax.(209)468-3433 • Web:www.sjcelid.com <br /> Ilia' <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL I X1 I I III III EHD LOG# <br /> B. SOURCE OF INFORMATION <br /> NAME: IJN (N-f- �l � �(� PHONE: <br /> COMPANY: ` r'\� / CITY: <br /> ADDRESS: U <br /> DESIGNATED EMPLOYEE NAME: PHONE: } <br /> REPORTING AGENCY NAME: <br /> ADDRESS: A <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: 2 - CITY /�� incorporated <br /> Best Physical Description ) �, �, � CA'q,, `� '^'"� <br /> Unincorporated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: TIME: <br /> 1 <br /> D. RESPONSIBLE PER SON/BUSINESS <br /> NAME OF BUSINESS: i <br /> CONTACT PERSON: Z�I r1 p rPHONE: <br /> PHYSICAL ADDRESS: ny� `�j �- \yy �` 1�i.�yb C `J7% <br /> MAILING ADDRESS: f fl , (A 1 SZU <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: ;n,► ,1!�;Iv <br /> CHEMICALS: ! - <br /> CIRCUMSTANCES: �y , Q� Gll� Oil {N litm `( ` ' !N �c azl- . <br /> 1 <br /> F. ACTION TAKEN <br /> Ila" 4Q-, ' �, i, <br /> v�u <br /> A� e - <br /> I WIW <br /> SITE DISPOSITION <br /> PROP 65 Revised 07/27/12 <br />