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PaV IN•. SAN ,JOAQIIIN COUNTY <br /> _ ay ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br /> • _ (209)468-3420•Fax:(209)464-0138- Web:www.co.san-joaquin.ca.us/ehd <br /> q�f ora <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 25180.7 <br /> EHD LOG#: <br /> A. EMERGENCY LEVEL: I� II III <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> � Phone: Va9) 5A,2-02-23 <br /> Name: <br /> Company: <br /> ���-, (�p,�Q�yy,1,•U. OJW- r3 Zt/oCity: 114-p0,A 'o _Zip Code: <br /> Address: o <br /> Designated Employee Name: <br /> Reporting Agency Name: Cit Zip Code: <br /> Address: y' <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Al. f3L"J& .a- (JIS'� �to"�t�'- / Cit �r County <br /> Location: �� ircle One) <br /> (Best Physical Description) <br /> Date of Discharge: /rM r,vau 4� Date Notified: CJJ Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> # e <br /> Name of Business: �'`' <br /> Phone: ( ) <br /> Contact Person: Cit Zip Code: <br /> Physical Address: y' <br /> Cit /� d , CCA Zip Code: 9 <br /> Mailing Address: /0 W-4 y' <br /> E. DESCRIPTION <br /> Type of Discharge: C!M <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> S <br /> F. ACTION TAKEN: <br /> � S• � � �t� cow <br /> SITE DISPOSITION: <br /> Notification of Haz Discharge <br /> F.HD 22-0?-M3 <br />