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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT 0017 <br /> 0. <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209) 468-3420 - Fax: (209) 464-3433 - Web:www sagov.orq/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL Ffl i ❑ ii El w EHD LOG# I C::� <br /> B. SOURCE OF INFORMATION <br /> NAME: P�"A Z �k)zwt\k PaLlvib PHONE: <br /> COMPANY CITY: <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: <br /> REPORTING AGENCY NAME: San Joaquin County Environmental Health Department <br /> ADDRESS: 1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: 1 Incorporated <br /> Best Physical CITY <br /> Description Unincorporated <br /> DATE OF DISCHARGE: Klaq <br /> DATE NOTIFIED a U, TIME: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: ff-71: S, <br /> CONTACT PERSON: Al-3 A)A0 PA(JA 0 Oj� PHONE: <br /> PHYSICAL ADDRESS: I - <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME. L)a('ti <br /> CHEMICALS: ca y1to <br /> CIRCUMSTANCES: Uvi 45 kyzly-S w <br /> F. ACTION TAK�9N <br /> �Sc C�Upvp u0y�ch r's rso',D K4 'ii <br /> SITE DISPOSITION <br /> SAIIf 6, (JA CAkJ,_ VU* e(- K-St&Y,4 <br /> Revised 08/02/12 Page 1 of 2 NOTIFdCATION OF HAZ WASTE DISCHARGE <br />