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qu�" SAN JOAQLJIN COUNTY <br /> r <br /> ENVIRONMENTAL HEALTH DEPART <br /> MT <br /> 304 East Weber Avenue, 3`d Floor, Stockton`; CA 95202-2708 i' , <br /> (209)468-3420•Fax:(209)464-0138 w3 b:w%% w.co.sanjoaquin.caxs/chd <br /> ( FptZ <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health S Safety Code, Section 251:80.7 <br /> EHD LOG##: ��►� [3 <br /> A. EMERGENCY LEVEL: II <br /> (Cizcle One) ;3 . <br /> B. SOURCE OF INFORMATION <br /> Phone: (db D Z`t 3 <br /> Name: <br /> Company: C-�-.c o Pte- <br /> an ' fo Zip Code: <br /> Address: Z�laCity: <br /> Designated Employee Name: <br /> Reporting Agency Name: Cit Zip Code: <br /> Address: y�� <br /> C. LOCATION AND DATE OF DISCHARGE i,. <br /> . 6 �/. Cit r Co <br /> �u�t.� �lS'�� unty <br /> LoCatiori: ircle One) <br /> (Best Physical Description) <br /> Date of Discharge: w+,t <br /> Date Notified: <br /> D. RESPONSIBLE PERSONBUSINES S a <br /> Name of Business: -�`' <br />'F /! Phone: ( ) <br /> Contact Person: Cit I.: Zip Code: <br /> Physical Address: Y <br /> Mailing Address: D <br /> City: i —Zip Code: 9 <br /> E. DESCRIPTION <br /> Type of Discharge: LVA <br /> Volume: '°"�"� <br /> Chemicals: <br />• Circumstances: <br /> E S <br /> F. ACTION TAKEN: <br /> SITE DISPOSITION: - <br /> n n / �/ . •� •-` oil � <br /> us <br /> U✓t-�`� � Notification of Haz Discharge <br /> RHD 22-02-403 i <br />