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SAN JOAa.QUIN COUNTY <br /> .. '? ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420 • Fax:(209) 464-3433 • Web:www.sigov.org/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL 01 ❑ il ❑ 1l1 EHD LOG# <br /> B. SOURCV OF INFORMATION/.---- <br /> NAME: <br /> NFORM TIONNAME: PHONE: 7 <br /> COMPANY: San Joaquin County Environmental Health Department CITY: Stockton <br /> ADDRESS: 1868 E. Hazelton Ave. <br /> DESIGNATED EMPLOYEE NAME: PHONE: 3 <br /> REPORTING AGENCY NAME: San Joaquin County Env' nmental Health Department <br /> ADDRESS: 1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: <br /> � Incorporated <br /> Best Physical CITYDescription /n� ^ M � J� <br /> Unincorporated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: '17/11 <br /> D. RESPONSIBLE PERSON/B SINESS <br /> NAME OF BUSINESS: // <br /> CONTACT PERSON: PHONE: <br /> PHYSICAL ADDRESS: d C S! <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: <br /> CHEMICALS: / 1 <br /> CIRCUMSTANCES: `N'�' �,{ (M <br /> F. ACTION TAKEN <br /> SITE DISPOSITION — <br /> C/--up <br /> Revised 08/02/12 Page 1 of 2 NOTIFICATION OF HAZ WASTE DISCHARGE <br />