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oPquirl SAN JOAQUIN COUNTY <br /> �? ? ENVIROI��VIE�N4T^AL HEALTH DEPARTMENT <br /> (g 6g a0b East aIn Sireet Stockton•CA 952023029 LI <br /> P (209)468-3420•Fax:(209)464-0138• Web:wwvAieov.ore/ehd <br /> 9t%PORN <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL I x I I JEHDLOG# I i - <br /> B. SOURCE OF INFORMATION <br /> NAME: PHONE: 20 <br /> COMPANY: ( r CITY: <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: PHONE: . <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: `(f q 0Q W. A/y 12 6t-E- {�- CITY � � Incorporated <br /> Be: Physical Deuriptivv / ��tt <br /> (Jt ;S' ( o, •{� VIILLUninco orated <br /> DATE OF DISCHARGE: gF—O <br /> DATE NOTIFIED: Z TIME: <br /> D. RESPONSIBLE PERSONBUSINESS <br /> NAME OF BUSINESS: . K4 19 A <br /> CONTACT PERSON: ®„dt r PHONE: ZJ7CI 9 <br /> PHYSICAL ADDRESS: Q <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> n <br /> TYPE OF DISCHARGE: Lj / <br /> VOLUME: <br /> CHEMICALS: G5 <br /> Y�J <br /> CIliCUMSTANCES: <br /> F.JJ ACTION TAKEN(( <br /> 4/ �j�C-TLm <br /> C071laNl/Vlq . ��(�Q,6aCioY1 -� 3�i� <br /> s; <br /> b �b con- <br /> � rm <br /> d . w �A pro,,efa- �" clp <br /> SS ��EAADIISPOSITION �a..s <br /> �vR l Cw <br /> ER RECORD MODIFIED Revised 05/012007 <br />