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SAN JOAQUIN COUNTY Q <br /> v^. °o <br /> G <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton• CA 95202-3029 i <br /> ' (209)468-3420•Fax:(209)464-0138 • Web:www.sigov.org/ehd � <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL Lx I I I Iu III EHD LOG# <br /> B. SOURCE OF INFORMATION p <br /> NAME: 1_ r11L 7 Ct. PHONE: 1 S I S S I <br /> COMPANY: V 1I1q CITY: <br /> ADDRESS: 6.+ (�rreaxgn� <br /> DESIGNATED EMPLOYEE NAME: PHONE: �---� <br /> REPORTING AGENCY NAME: ^'----�� <br /> ADDRESS: - <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: r r ,y.�e. L. crJ CITY Inco orated <br /> Best Physical Description <br /> k SPz.. <br /> Unincorporated <br /> DATE OF DISCHARGE: —7 <br /> DATE NOTIFIED: 7 TIME: 10 ;00 <br /> a� <br /> D. RESPONSIBLE PERSONIBUSINESS <br /> NAME OF BUSINESS: jV <br /> CONTACT PERSON: <br /> PHYSICAL ADDRESS: <br /> MAILING ADDRESS: � <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: O� <br /> CHEMICALS: �y 4 <br /> CIRCUMSTANCES: <br /> F. ACTION TAKEN 1 <br /> !`"l�+r►vw l7tr5or+w CZar�a i ��So��,,•- �pi�i (.�J b +~-5 a J <br /> SITE DISPOSITION <br /> G�cs... vim'► . <br /> ER RECORD MODIFIED Revised 05/01/2007 <br />