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�oKqR INco SAN JOAQUIN COUNTY <br /> _'` '` ENVIRONMENTAL HEALTH DEPARTMENT 4 <br /> 600 East Main Street Stockton CA 95202-3029 <br /> (209)468-3420•Fax:(209)464-0138 • Web:www.sizoy.ors/e11d <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHA p <br /> l <br /> } A. EMERGENCY LEVEL 1XII u n EHD LOG# <br /> Q-d � <br /> B. SOURCE OF INFORMATION <br /> s NAME: }l�fi /G e. PHONE: ^6p [73 <br /> COMPANY: C CITY: <br /> t ADDRESS: s� <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ii <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: '51.5 67— CITY Incorporated <br /> Rest Physical Description <br /> Uninco orated <br /> DATE OF DISCHARGE: -7— <br /> DATE <br /> DATE NOTIFIED: <br /> 0 9 TIME: <br /> ' D. RESPONSIBLE PERSON/BUSINESS <br /> t <br /> NAME OF BUSINESS: r <br /> i; CONTACT PERSON: /� PHONE: <br /> PHYSICAL ADDRESS: 5-7 5r d rcA <br /> cur <br /> + MAILING ADDRESS: <br /> E. DESCRIPTION <br /> ij 1 <br /> E <br /> TYPE OF DISCHARGE: i <br /> a VOLUME: <br /> t <br /> c� CHEMICALS: <br /> ' CIRCUMSTANCES: ere,-, <br /> ,a F. ACTION TAKEN <br /> } <br /> SITE DISPOSITION <br /> 1 <br /> ER RECORD MODIFIED Revised 05/01/2007 <br /> I <br /> i <br /> j <br /> .i <br /> + 4 <br />