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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> . 1868 E.Hazelton Ave., Stockton• CA 95205 <br /> (209)468-3420•Fax:{209}468-3433 - Web:www.sjcehd.com <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL I x IILJII III EHD LOG# <br /> B. SOURCE OF INFORMATION �S <br /> NAME: PHONE: o OR, 3 2"6 �I 0 Z/ <br /> COMPANY: � � � � , CITY: <br /> ADDRESS: //OF <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISC GE <br /> LOCATION: a/Sb I6• CITY // incorporated <br /> Hest Physical Description U ��r / <br /> Y Uninco orated <br /> DATE OF DISCRARGE: ZC �!� <br /> DATE NOTIFIED: / a '-// --l Z <br /> D. RESPONSIBLE PER NIBUSINESS <br /> NAME OF BUSINESS: 77! <br /> / p <br /> CONTACT PERSON: PHO 7r0 <br /> PHYSICAL ADDRESS: �a & 6 M Z-Z- <br /> MAILING <br /> MAILING ADDRESS: S /¢ <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: y ci <br /> CHEMICALS: <br /> CIRCUMSTANCES: 711" ALS <br /> F. ACTION TAKEN <br /> zo-k w r Z <br /> SITE DISPOSITION <br /> 60-1 < <br /> PROP 65 Revised 07/27/12 <br />