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o gyiy..c <br />° SAN JOAQUIN COUNTY <br />FILEENVIRONMENTAL HEALTH DEPARTMENT COPY <br />'304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />(209) 468-3420 • Fax: (209) 464-0138 • Web: www.co.san-joaquin.ca.us/ehd - <br />�FOR <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />California Health & Safety Code, Section 25180.7 <br />EHD LOG #: 644 Q (_oj <br />A. EMERGENCY LEVEL: I 3 , <br />(C One) <br />B. SOURCE OFINFORMATION <br />Name: AlTl�P J� ovl Phone: (2o7) <br />Company: S<tt1 �l/IQOrrin G.,N�i r/ Fien� �bt�.rl <br />Address: 30 t% lZr ul2 be r City: _�>-{cc J <br />Designated Employee Name: Zip Code: <br />Z� z <br />Reporting Agency Name: <br />Address: City: Zip Code: <br />C. LOCATION AND DATE OF DISCHARGE <br />Location: `f73 A) dt (`�3�eeei ino�/, Q�{& fi Cit rCount <br />(Best Physical Description) SV 5{• ucle One) <br />Date of Discharge: Date Notified: /3G (O Time: 79,zir.M. <br />D. RESPONSIBLE PERSON/BUSINESS <br />Name of Business: C C l Za9� t%G <br />Contact Person: 0TPP9one: (z 7) `237-856-1/ <br />Physical Address: N G -add City: Zip Code: rlS2�� <br />Mailing Address: !l1 L2� City: Si�rr :� Zip Code: (yjS a Z <br />E. <br />F. <br />DESCRIPTION <br />Type of Discharge: <br />Volume: <br />Chemicals: <br />Circumstances: <br />ACTION TAKEN: <br />SITF, DISPOSITION: <br />Notification of Haz Discharge <br />EED-a-M-WS <br />