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'° cp SAN JOAQUIN COUNTY <br /> G <br /> y "ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue;P Floor, Stockton, CA 95202-2708 <br /> • > - <br /> 209)46 8-3420-Fax:(249)4640138 • Web: www.6o'san-joaquin.ca.us/ehd <br /> � FoRa j <br /> ' IFICATION OF HAZARDOUS WASTE DISCHARGE <br /> bG California Health & Safety Code, Section 25180.7 <br /> c�• EHD LOG <br /> A. EMERGENCY LEVEL: I II III <br /> (Circle Orae) <br /> B. SOURCE OF INFORMATION <br /> Name: . IC ea.h.ea.•0w <br /> Phone: Ve4) <br /> Company: t_c j 7_c c A w_4 c s <br /> Address: 1 d 7�. City: 04o a 6A • Zip Code: SSS <br /> Designated Employee Name: <br /> Reporting Agency Name: a- E14_16� <br /> Address: C� � City: Zip Code: 93- -o Z <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: N [b W G h C 4ivI / City or ount <br /> (Best P&sical Description) (Circle <br /> Date of Discharge: 1w_ w� Date Notified: ZkYlo r Time: " 10=00 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: Qx4,w� - go--e—U.- Sri! - Z(?y3 r4�UL4 <br /> Contact Person: t--- f A Phone: { ) <br /> Physical Address: v Q City: Zip Code: <br /> Mailing Address: t 5(2- r, Q-L A City: #LodtA CA.Zip Code: t S-fd <br /> J <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: .�wCtR.S.�i�_ _ <br /> Circumstances: l,ZST S <br /> F. ACTION TAKEN: dOSa <br /> 5 <br /> SITE DISPOSITION: r ads fes+•-t- <br /> CAL <br /> EHD 22-02-003 Notification of Haz Discharge <br /> 10/2/2003 <br />