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�FED � <br /> J <br /> SAN JOAQUIN COUNTY <br /> ub <br /> ENVIRONMENTAL HEALTH DEPARTMENT1868 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 II II III EHD LOG# ?j-Q <br /> \L B. SOURCE OF INFORMATION <br /> NAME: glAlk usOh/ PHONE: (f(-06 . 8 <br /> COMPANY: 6&tgA/14 06,S CITY: <br /> ADDRESS: 5 AC- C <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> \ LOCATION: ak/T0D � � ���, CITY ` dA�tD Inco orated <br /> V Best Physical Description Com-[ <br /> Q i Unincorporated <br /> DATE OF DISCHARGE: lip 1-5 <br /> DATE NOTIFIED: zoi TIME: ��Lv/'E•�'� <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: <br /> CONTACT PERSON: ,�/y�• PHONE: Zb� <br /> PHYSICAL ADDRESS: Z Q � C <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: t D D <br /> CHEMICALS: <br /> CIRCUMSTANCES: Q7.-'_ <br /> F. ACTION TAKEN <br /> ez't <br /> SITE DIS"TION <br /> PROP 65 Revised 07/27/12 <br />