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1 G� <br /> Pa"1N SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT \ <br /> 600 East Main Street Stockton . CA 95202-30291714x_ /`% <br /> (209)468-3420•Fax. (209)464-0138 • ff eb: www.siQov.org/ehd `-- <br /> O - <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL X I II 1u III EHD LOG# <br /> B. SOURCE OF INFORMATION <br /> NAME: A C21% , w PHONE: <br /> COMPANY: _ �„� ,� CITY: <br /> ADDRESS: I tL <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: <br /> Ben Physical Dexriptivv �� I� �"'� �"� Z-Iv`� /�aG'` COY � � � Incorporated <br /> Urrinco orated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: _ _ p TIME: 7 44 S <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: �— <br /> CONTACT PERSON: ��� , � PHONE: 9_ 6_5-7 <br /> PHYSICAL ADDRESS: p� v Q� p�� S 30 <br /> MAILING ADDRESS: ^� Z <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: .5 ) <br /> VOLUME: q0, �✓0,�5 <br /> CHEMICALS: <br /> CIRCUMSTANCES: <br /> F. ACTION TAKEN �^y // / n <br /> SITE DISPOSITION// <br /> ER RECORD MODIFIED Revised 05/01/2007 <br />