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t' SAN JOAQUIN COUNTY <br /> Ejl�ONMENTAL HEALTH DEPARTpt-NT 0-4 -Nog <br /> 304 East Weber Avenue,3rd Floor, Stockton, <br /> CA 95202-2708 <br /> P (209)468-3420•Fax:(209)464-0138 • Web:www.co.san-joaquin.ca.us/ehd <br /> c F a NOTIFICATION OF HAZARDOUS WASTE DISCHAALE COP <br /> California Health & Safety Code, Section 25180.7 <br /> EHDLOG#: <br /> A. EMERGENCY LEVEL: I II III <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: tie C ,�+�� Phone: ( ) <br /> Company: <br /> Address: ' City: Da&15 Zip Code: 1 -5-5,44, <br /> Designated Employee Name: <br /> Reporting Agency Name: �c 3'6 G w (!�o cS,i.)i ro t4/yt✓ � �'�b <br /> Address: City: - c! V/- UB�n- Zip Code: <br /> C. LOCATION AND DATE OF D CHARGE (�� � ` ay L C- <br /> O + /�j 1� y-e. / Ci` r Count <br /> Location: (Circle One) <br /> (Best Physical Descnphon) <br /> Date of Discharge: -J u <br /> _ Date Notified: i Z1,, c t( Time: -3 A.M. <br /> D. RESPONSIBLE PERSONBUSINESS <br /> Name of Business: 7A 0 4 7v-e- <br /> Phone: (q( ►61 <br /> Contact Person: _& r 5i lol e- <br /> r,) 2�o- 0 <br /> Physical Address: 2 o t 4 I- S. U i 1 :acNv City: C cr so�- C�cZip Code: 4 pg 6a <br /> Mailing Address: S h o 4 a c s o bei ity: Zip Code: <br /> E. DESCRIPTION <br /> Type of Discharge: " i <br /> Volume: I A7 IL <br /> Chemicals: M— — X 4u Mol <br /> reCircumstances: <br /> F. ACTION TAKEN: v eau fes-- S40EM) <br /> SITE DISPOSITION: hoc Prw — <br /> Notification of Haz Discharge <br /> EHD 22-02-003 <br /> 10/2/2003 <br />