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SAN JOAQUIN COUNTY O py <br /> rn= <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave., ,Stockton - CA 95205 <br /> (209)468-3420.Fax:(209)468-3433 - Web:www.sicehd.com <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL x=11m= EHD LOG# <br /> B. SOURCE OF INFORMATION <br /> NAME: W I/( QJZ_ PHONE: ai 'Z3(—'?1 D <br /> COMPANY: W/Y1^� ,t/�,� CITY: <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DA OF DISCHAR E <br /> LOCATION: - fitv CITY 5 �� Incorporated <br /> 13est Physical Description —000 S. <br /> Q �A � w <br /> �]VV �] C.[J�+a..P Uninco orated <br /> DATE OF DISCHARGE: a 20C <br /> DATE NOTIFIED: W 2-013 <br /> TIME: 7:QD <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSRNF_8S: C k J&, ltd_ t &4,-, a lh Irk <br /> CONTACTPERSON: PHONE: <br /> PHYSICAL ADDRESS: <br /> MAILING ADDRESS: S <br /> /A <br /> E_ DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: r, nA <br /> CHEMICALS: A <br /> CIRCUMSTANCES: aj,� � <br /> F. ACTION TAKEN <br /> s.+� 4 <br /> r <br /> beeDktl <br /> . <br /> Me. PW) atk /- ru-t Af16 <br /> SITE DISPOSITION <br /> S <br /> MA-i - L�P-f, C"a- rn eau42pAtma. <br /> oAtftl4 AiL <br /> Aolo <br /> PROP 65 Revised 07/27/12 <br />