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SAN JOA UIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> y. 600 East Main Street Stockton • CA 95202-3029 <br /> f a. (209)468-3420•Fax:(209)464-0138• Web:www.s' ov.or eh `` _ <br /> =�►i o'sir'�P ` <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL x II II III EHD LOG# f — 0 S <br /> B. SOURCE OF INFORMATION /- <br /> NAME: PHONE: 2Q9 DGP 9 / <br /> COMPANY: /re CITY: �Q <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: ��� ^r/,�j�� PHONE: (2O� <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. .LOCATION AND DATE OF DISCHARGE . <br /> LOCATION; /''. / ,�/� CITY (y� Inco oratedBegaPhysical s� nescriptioo !N <br /> Uninco orated <br /> DATE OF DISCHARGE: �Q <br /> DATE NOTIFIED: TIME: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: C 7_f <br /> CONTACTPERSON: <br /> PHONE: <br /> PHYSICAL ADDRESS: <br /> MAILING ADDRESS: 815 <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: �Q <br /> CHEMICALS: Y dZ <br /> CIRCUMSTANCES: <br /> F. ACTION TAKEN <br /> d�L MI Zv f ua' c1'r�2 a�z711a e.10 <br /> SITE DISPOSITION <br /> 11 7'9 Zloty <br /> ER RECORD MODIFIED Revised 05/01/2007 <br />