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SAN JOAQUIN 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 EHDLOG# <br /> EMERGENCY LEVEL: <br /> ❑X I-No EvacuationlLocal Response Only ❑II-Evacuation and/or In-County Mutual Aid Needed ❑III-Evacuation and/or RegionallState Mutual Aid Needed <br /> SOURCE OF INFORMATION <br /> NAME: Michelle Henry PHONE: (209)468-3454 <br /> COMPANY: San Joaquin County Environmental Health Department CITY: Stockton <br /> ADDRESS: 1868 E. Hazelton Ave. <br /> DESIGNATED EMPLOYEE NAME: Michelle Henry PHONE: (209)468-3454 <br /> REPORTING AGENCY NAME: San Joaquin County Environmental Health Department <br /> ADDRESS: 1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br /> LOCATION AND DATE OF DISCHARGE <br /> LOCATION: n _ /�,��,� ❑ Incorporated <br /> Best Physical _ /,f �, � CIT Iti-"""" � 'Unincorporated <br /> Description WW <br /> DATE OF ^ <br /> DISCHARGE: / <br /> DATE TIME: <br /> NOTIFIED: <br /> RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: <br /> CONTACT PERSON: w.... PHONE: <br /> PHYSICAL ADDRESS: I_ 'l <br /> MAILING ADDRESS: DB 6 V <br /> DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: N1- <br /> CHEMICALS: '/ Y(.[ <br /> CIRCUMSTANCES: V <br /> ACTION TAKEN <br /> J&A& f4l16/ <br /> SITE DISPOSITION <br /> Revised 6/01/2015 Page 1 of 2 NOTIFICATION OF HAZ WASTE DISCHARGE <br />