Laserfiche WebLink
N. <br /> PQUI" SAN JOAQUIN COUNTY i <br /> 'O+�•COG �,.,d `'- a. C.I <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton• CA 95205 <br /> (209)468-3420•Fax:(209)468-3433 • Web:www.sjcehd.com <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL I x I II III EHD LOG# (+ -p <br /> B. SOURCE OF INFORMATION <br /> NAME: `` PHONE: — <br /> COMPANY: / C CITY: <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: Jeffrey Wong PHONE: (209)468-0335 <br /> REPORTING AGENCY NAME: SIC EHD <br /> ADDRESS: 1868 E.Hazelton,Stockton <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: Co U CITY Incorporated <br /> Best Physical Description <br /> Unincorporated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: TIME: ro <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: <br /> CONTACT PERSON: Q�,. PHONE: <br /> PHYSICAL ADDRESS: <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: (,� 01 <br /> CHEMICALS: <br /> CIRCUMSTANCES: S t <br /> 1. <br /> F. ACTION TAKEN <br /> ( (W-K; - I --(ik? 4jq <br /> dY1 MUS�-r-[dye c� C. /vq U' <br /> SITE DISPOSITION <br /> C � <br /> PROP 65 Revised 07/27/12 <br />