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SAN JOAQUIN COUNTY <br /> oA NiBD <br /> c <br /> 2bn? ENVIRONMENTAL HEALTH DEPARTMENT <br /> W . 600 East Main Street Stockton • CA 95202-3029 <br /> (209)468-3420•Fax:(209)464-OI38 • Web:www.s oV.ar lehd y <br /> o NOTIFICATION OF HAZARDOUS WASTE DISCHARG = ,j� + � <br /> A. EMERGENCY LEVEL X I j I II IH EHD LOG# )1- <br /> B. SOURCE OF INFORMATION <br /> NAME: PHONE: <br /> COMPANY: CITY: <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> S <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: j� CITY {/Q�.J�/j� Incorporated i <br /> Best Physical Description flan" Vv•�/� <br /> J/ � ' Unincorporated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: -7 TIME: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: -�f <br /> CONTACT PERSON: PHONE: <br /> PHYSICAL ADDRESS: <br /> MAILING ADDRESS: O ha <br /> i� E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: <br /> CHEMICALS: J <br /> CIRCUMSTANCES: <br /> F. ACTION TAKEN <br /> pofm <br /> i <br /> SITE DISPOSITION <br /> per , rte; <br /> ER RECORD MODIFIED Revised 05/01/2007 <br />