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16:9"�" :�,. SAN JOAQUIN COUNTY r' <br /> J <br /> °ur ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 I <br /> (209) 468-3420 • Fax: (209) 464-3433 • Web:www.sl-gov.org/ehd <br /> R<<F <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL 0 1 ❑ II ❑ In EHD LOG# 14-o51 <br /> B. SOURCE OF INFORMATION <br /> — <br /> NAME: PHONE: <br /> COMPANY: CITY: r CA <br /> ADDRESS: c -[. <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: San Joaquin County Environmental Health Department <br /> ADDRESS: 1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: <br /> Incorporated <br /> Best Physical CITY <br /> Description <br /> A Unincorporated <br /> DATE OF DISCHARGE: v[' t 8j)A1I (S-1 <br /> DATE NOTIFIED: (bill TIME: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: - <br /> CONTACT PERSON; r ' PHONE: <br /> i <br /> PHYSICAL ADDRESS: LrA 4 r RNA'l 1, <br /> MAILING ADDRESS: . <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: �bkf , <br /> VOLUME: y� '- l G <br /> CHEMICALS: JV -C <br /> CIRCUMSTANCES: <br /> F. ACTION TAKEN <br /> kUIAs 1 , <br /> 11 G <br /> s ;if\�VV , <br /> SITE DISPOSITION <br /> ckalv�A'f (��w - P�u 6o-) <br /> Revised 08102112 Page 1 of 2 NOTIFICATION OF HAZ WASTE DISCHARGE <br />