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• �o oc SAN JOAQUIN COUNTY <br /> y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3'Floor, Stockton, CA M02-2708 yi P Y <br /> P (209)468-3420•Fax.(209)464-0138 . Web:www.co.san joaquin.ca.us/ehd <br /> qC/PORN <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 25180.7 <br /> EHD LOG#: No- <br /> A. EMERGENCY LEVEL R III <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: (_ I bl'1 Phone: (201) q93 / 3 <br /> Company: <br /> Address: l f 6�vw(t 0,v3 �1'r& City: Zip Code: SZ� <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: City: Zip Code: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: �3 5 5 0 5. liwLA q / City or ounty� <br /> (Best Physic escription) (Cin <br /> /c�le <br /> Date of Discharge: l�- 5 6 (0 Date Notified: l S Time: <br /> r O`r A.M. P.M. <br /> D. RESPONSIBLE PERSON/BUSINESS L� <br /> Name of Business: e QCAu 0e/ l� ( v f� <br /> Contact Person: Q L b n Phone: (A - <br /> Physical Address: ra vL c w K City: Zip Code: 2 0 6 <br /> Mailing Address: C City: Zip Code: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: 2 Q [L a+ ni ZZ e. <br /> F. ACTION TAKEN: (AN fLi1 J� <br /> SIDE DI POSITION: Pli4 <br /> -N} G <br /> Notification of Haz Discharge <br /> EHD 22-02-003 <br /> 10/2/2003 <br />