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SAN JOAQUIN COUNTY Q <br /> ENVIRONMENTAL HEALTH DEPARTMENT p <br /> 600 East Main Street Stockton.■.CA 95202-3029 <br /> ( (209)468-3420-Fax:(209)464-0138• Web:www.sjgoy.org/ehd py <br /> f/�\ <br /> NOTIFICATION OF HAZARDOUS WASTE DLSCHAR <br /> A. EMERGENCY LEVEL IX I I EHD LOG# i0- <br /> B. SOURCE OF INFORMATION <br /> NAME: J*�L 0+ kn PRONE: <br /> COMPANY: I S y(M, n CITY: <br /> ADDRESS: P ., <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: 63 C. cArmilikol a, CITY Imo rated <br /> Bm Pbywal oeserip ON 32- Agrs 10nincoMorated <br /> DATE OF DISCHARGE: It I <br /> DATE NOTIFIED: O <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: �Q V <br /> II CONTACT PERSON: Q �i PHONE: GZ� <br /> l PHYSICAL ADDRESS: V, S k n <br /> MAILING ADDRESS: <br /> 4 <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: <br /> CHEMICALS: 1V61r 3ZO/o MfylaeA <br /> CIRCUMSTANCES: I Cap Qq d i G <br /> F. ACTION TAKEN PA ' dell <br /> d,at V `co f r&c1 U r t Y1 Saxa AtQ,f1 D "fDv-pJ S-Wm <br /> In <br /> SITE DISPOSITION <br /> Ld+ L,gvzd fam stp <br /> I71,i n r n A-ST 0)/L <br /> ER RECORD MODIFIED Revised 05/0112007 <br />