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P a u i N SAN JOAQUIN COUNTY C�O n� <br /> �0 C� <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q: <br /> 1 1868 E.Hazelton Ave., Stockton• CA 95205 <br /> •'c - (209)468-3420■Fax:(209)468-3433 ■ Web:www.sjcehd.com <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL I x i II III EHD LOG# - ® (p <br /> B. SOURCE OF INFORMATION <br /> NAME: PHONE: C��Oj 7(-Iy'FZ <br /> COMPANY: CITY: <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: PHONE: p <br /> REPORTING AGENCY NAME: <br /> ADDRESS: o �7 o.- S�o�[c D✓� e�} [ S <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: 3l 1�C L��'r`•�ti CITY G�fJ , n Inco orated <br /> Best Physical Description <br /> Unincorporated <br /> DATE OF DISCHARGE: (p Z Mi;L- <br /> DATE NOTIFIED: /6 TIME: •(��./� <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: (9A CD 5;-1-> � 7 <br /> CONTACT PERSON: ,(- �� PHONE: <br /> PHYSICAL ADDRESS: <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: <br /> CHEMICALS: <br /> CIRCUMSTANCES: <br /> F. ACTION TAKEN <br /> k9-- V2- <br /> V <br /> �/Z 20 n->1 a.�- �/�..vim•n <br /> U <br /> U <br /> SITE DISPOSITION <br /> c f0'sz' Chit u� s� <br /> C1411 <br /> PROP 65 Revised 07/27/12 <br />