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SAN JOAQUIN COUNTY fill 6 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Stied Stockton• CA 95202-3029 <br /> N17(209)468-3420-Fax. (209)464-0138 - Web: www.sigov.org,/e <br /> NOTIFICATION OF, HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL I X I I III EHD LOG# <br /> B. SOURCE OF INFORMATION <br /> NAME: PH O,:N:E: �0,9- <br /> COMPANY: CITY- <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME:. <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: c 5rlke, <br /> CITY rated <br /> Best Physical ewription n�mcoora <br /> t <br /> ed <br /> DATE OF DISCHARGE: 1 6 /v&/ 1 <br /> DATE NOTIFIED: 6 TMlE: lLzso <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: \,ja,� 4- k- h,.,- <br /> CONTACT <br /> c,-CONTACT PERSON: t-,0 PHONE: 2c),q -7 <br /> PHYSICAL ADDRESS: <br /> MAILING ADDRESS: q--5112--O <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE. <br /> VOLUME: L>0 <br /> CHEMICALS: <br /> CIRCUMSTANCES: A,54— 4 )LOJ k,,}n, <br /> F. ACTION TAKEN <br /> FP E;�vM2,,%e—Ad 46 �,hmJlt �Y� <br /> SITE DISPOSITION <br /> A 2. kA 77r),r0 i'lvps, <br /> I ) <br /> ER RECORD MODIFIED Revised 05/01/2007 <br />