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SAN JOAQUIN COUNTY <br /> z ENVIRONMENTAL HEALTH DEPAAF A22 <br /> I� <br /> 600 East Main Street Stockton •CA 95202-3029L <br /> (209)468-3420•Fax:(209)464-0138 • II'eb:vm w.sieov.ore/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHAILF <br /> A. EMERGENCY LEVELEHD LOG# 0 W1Z. <br /> B. SOURCE OF INFORMATION <br /> NAME: fir 10 PHONE: <br /> COMPANY: i;yfG �i/,t CITY: ac� <br /> ADDRESS: LL r U, - L-4a . , a52o L <br /> DESIGNATED EMPLOYEE NAME: PHONE: i- <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: C"�g-' 5!c(x. o� 7 CITY Inco rated <br /> 0-F' 1066 Sia f� <br /> �' �—i15�� O� Uninmmorated <br /> DATE OF DISCHARGE: L41 G c <br /> DATE NOTIFIED: O ko TIME: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: L, u E, 'N - ✓"fc.F'fy^;� <br /> CONTACT PERSON: �, o�.� ' PHONE: - cj <br /> PHYSICAL ADDRESS: j'40 Np S G <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: <br /> CHEMICALS: <br /> CIRCUMSTANCES: <br /> F. ACTION TAKEN <br /> R p i i sPi`l7 �bs�b� cl�� JII, <br /> SITE DISPOSITION <br /> ER RECORD MODIFIED Revised 05/01/2007 <br />