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SAN.TOA UIN COUNTY �. <br /> y: ENVIRONMENTAL HEALTH DEPRTEN <br /> co <br /> c 600 East Main Street Stockton•CA 95202-3029 <br /> (209)468-3420-Fax:(209)464-0138- Web:www.sjgov.org/ehd <br /> 55 <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL EHD LO-G-#---F— <br /> B. SOURCE OF INFORMATION <br /> NAME: a5 PHONE: �tf. <br /> COMPANY: CITY: <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: Sp N �� CITY11 Inco rated <br /> Bea Physiucd Dmnpum 'l <br /> c- l2—Lima 1 01^ Uninco rated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: <br /> o TIME: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS. sI r Y1s <br /> CONTACT PERSON: PHONE: QLID-32,m <br /> PHYSICAL ADDRESS: E,, 19:01f 2925 <br /> MAILING ADDRESS: i O Z <br /> E. DESCRIPTION p,6 <br /> TYPE OF DISCHARGE: C4, J <br /> VOLUME: 10 ^-5' <br /> CHEMICALS: <br /> CIRCUMSTANCES: j <br /> F. ACTION TAKEN 11 <br /> Mee <br /> P <br /> SITE DISPOSITION <br /> s/�i+�.�-.p Goy--�/►IA-6—� <br /> ER RECORD MODIFIED Revised 05/012007 <br />