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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT Q �� <br /> � € 1868 E.Hazelton Ave., Stockton • CA 95205 <br /> (209)468-3420 •Fax:(209)468-3433 • Web:www.sicehd.com <br /> t,fiou <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL x I u III EHD LOG# <br /> B. SOURCE OF INFORMATION <br /> NAME: LJGt� P14ONE: S!z (.9 g0069 <br /> COMPANY: CITY: <br /> ADDRESS: C aA, PD.ao 60-V OA 44 <br /> DESIGNATED EMPLOYEE NAME: k,V�}t,(i PRONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: I 1?6e S pc CA gSaa r <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: & ,c � CITY LA.t- oPj ✓ Inco orated <br /> Bem Physical Description <br /> `F5374D Unincorporated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: (� j Q ►i 6 : TIME: �; �f o�•... <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: CO IN. P 6,40 80 <br /> CONTACT PERSON: PHONE: Cf('Z 6f! _Var6 <br /> PHYSICAL ADDRESS: TQC <br /> MAILING ADDRESS: _0. 9d Q N- 6A 90-707- <br /> E. <br /> d?OZE. DESCRIPTION <br /> TYPE OF DISCHARGE: i <br /> VOLUME: V7- .,2, <br /> . <br /> CHEMICALS: <br /> CIRCUMSTANCES: p <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> d14. --41,4)-11 n�-�l /Ivl '' <br /> iC <br /> PROP 65 Revised 07/27/12 <br />