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a SAN JQA !foul <br /> E <br /> �L A.. DEPARTMENT <br /> ENVIROI��� i <br /> 304 East Weber Avenue;3`d Floor, Stockton,CA 95202-2708 <br /> (209)468-3420•Fax:(209)464-0138• Web:www.co.san-joaquin.ca.us/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 25180.7 <br /> EHD LOG#: <br /> A. EMERGENCY LEVEL[ ) 11 III <br /> ��--/ (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: n S'► Me N e,?— <br /> Phone: <br /> ��n <br /> Company: Fl ���B Zip Code: 3 <br /> Address: cS ) L 'S• �4G�'� T�� ISD- City: <br /> Designated Employee Name: A <br /> I/DN '� wLi <br /> Reporting Agency Name: SA'� ¢. e �`4'�� <br /> Address: <br /> u City: � Zip Code: � <br /> C. LOCATION AND DATE OF DISCHARGE Cit r County <br /> �c� 1 S• G1� ne- feD <br /> Location: oCircle One) <br /> (Best Physical Description) <br /> Time: <br /> Date of Discharge: l Z Z 0 3 Date Notified: L 6 <br /> 6 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> FI f N T 7"f u P l LA- <br /> Name Name of Business: Phone: (09^) <br /> Contact Person: Ti� e�'G2' <br /> �•,� 24 City: f Dc3D`1 Zip Cod <br /> e:�S366 <br /> Physical Address: i 5� S• S — ` � , UTZip Code: <br /> Mailing Address: L4 1 a <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: '" 2D KGlcn <br /> Chemicals: �r6r 0 /- <br /> Circumstances: � �«( (�1O <br /> jA b rn, � <br /> F. ACTION TAKEN: C< <br /> Dn <br /> SITE DISPOSITION: <br />