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oPa"I" c SAN JOAQUIN COUNTY <br /> y ` ENVIRONMENTAL HEALTH DEPARTMENT , <br /> 600 East Main Street Stockton ■ CA 95202-3029a 7 <br /> lY'�/ <br /> ' (209)468-3420-Fax:(209)464-0138 • Web:www.siQov.org/ehd <br /> qt%FORM � ,•'"� <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL I x EHD LOG# - <br /> B. SOURCE OF INFORMATION <br /> NAME: J ."W'O w PHONE: O —5 7;� <br /> COMPANY: , w„e CITY: <br /> ADDRESS: 3010 Lj <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: / CITY Incorporated <br /> 13es[Physical Description 3 0 I� L—) �"'� `1�^C /�a S e� I l/c,t <br /> Uninco orated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: _ _ v TIME: 2, <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: I.... r �— <br /> CONTACT PERSON: �� , ,,,�� PHONE: 1— 2(3 6,—5-7 Z�� <br /> PHYSICAL ADDRESS: p O � p� _ //tie:c S3-0,74 <br /> MAILING ADDRESS: 7010 <br /> q57 ,D <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: <br /> CHEMICALS: <br /> CIRCUMSTANCES: <br /> F. ACTITI�ON TAKEN <br /> SITE DISPOSITION <br /> G/QG,".p <br /> ER RECORD MODIFIED Revised 05/01/2007 <br />