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v <br /> oAQ s'` c SANT JOAQUIN COUNTY rc <br /> d <br /> ENVIRONMENTAL HEALTH DEPARTMENT L <br /> x 500 East Main Street Stockton - CA 95202-3029 <br /> (209)458-3420•Fay(209)464-0138• Web:www.s' ov.or ehd <br /> NOTIFICATION OF HAZARDOUS `BASTE DISCHAR 0 [Py <br /> A. EMERGENCY LEVEL I X 11 1 1 EHD LOG# <br /> B. SOURCE OF INFORMATION <br /> NAME: CQr -rcdd PHONE: <br /> COMPANY: Gic►`(" � �- LL-G CITY: <br /> ADDRESS: 30a!�' KaVq04-tM <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: �v(2 aV�f b Yt V°e I•y f, i rated <br /> Best Physical Description <br /> Uninco orated <br /> DATE OF'DISCHARGE: cc) as d u <br /> DATE NOTIFIED: �� Q TIME: KS <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: Paci z, Ltoyp <br /> CONTACT PERSON: PHONE: '�J <br /> PHYSICAL ADDRESS: (?�� �(/� <br /> MAILING ADDRESS: CS�IV�P� <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: 0' <br /> VOLUME: <br /> CHEMICALS: i Y c R <br /> CIRCUMSTANCES: we t c4 n ecA an <br /> F. ACTION TAKEN <br /> 4-b Pfau davile C. P��, 4D 5-hp f)en� <br /> SITE DISPOSITION j ff� <br /> 5 ro�Pri v � remove, f5vat r� � d 1 n--; oil cko wp4 J&zV Gl �t <br /> � <br /> ER RECORD MODIFIED Revised 05/03/2007 <br />