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SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �yc (209)468-3420•Fax:(209)464-3433- Web:www.siaov.oro/ehd <br /> 0 <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL x❑I ❑II ❑III EHD LOG# <br /> B. SOURC OF INFN ORM TIO <br /> NAME: PHONE: <br /> COMPANY: San Joaquin County Environmental Health Department CITY: Stockton <br /> ADDRESS: 1868 E. Hazelton Ave. <br /> A�W <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: San Joaquin County Env nmental Health Department <br /> ADDRESS: 1868 E. Hazelton Ave.,Stockton,CA 95205-6232 <br /> C. LOCATION AND DATE OF DISCHARGE FST-1 <br /> LOCed <br /> ATION: n�� ^ vCITY Unfnco�1ipo�atedBest Physical V•,t! J /I/I ry Ll <br /> Desa dan <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: I TIME: <br /> D. RESPONSIBLE PERSON/B SINESS <br /> NAMEOFBUSINESS: I 0I <br /> . ',a '/ <br /> CONTACT PERSON: ��yl�f PHONE: <br /> PHYSICAL ADDRESS: d C ' <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: /"IC <br /> VOLUME: N <br /> CHEMICALS �I'Aye�,y/ ///ol <br /> CIRCUMSTANCES: ' ' " �, "�"� 4 <br /> F. ACTION TAKEN � [�� � ✓. � <br /> SITE DISPOSITION <br /> Revised 08/02/12 Page 1 of 2 NOTIFICATION OF HAZ WASTE DISCHARGE <br />