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H <br />z <br />• <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton • CA 95205 <br />(209) 468-3420 • Fax: (209) 468-3433 • Web. www.sjcehd.com <br />c��py <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />A. EMERGENCY LEVEL x I a nI [ EH LLOG# =Q 5q <br />B. SOURCE OF nvFORMATYONT <br />NAME: <br />L <br />PRONE: <br />COMPANY: Lt.t� .f�k.e t <br />CITY: <br />ADDRESS: <br />PHYSICAL ADDRESS: <br />DESIGNATED EMPLOYEE NAME: <br />PHONE: <br />5ZA <br />REPORTING AGENCY NAME: <br />ADDRESS: <br />C. LOCATION AND DATE OF DISCHAR E <br />LOCATION: o► - L -t LO l 4"-' ZDAf WLF CTTy ` f �� Incorporated <br />Hat Physical Descriptica O wp > �T <br />'� V�/ •i z'% ! _ Uninco orated <br />DATE OF DISCHARGE: <br />DATE NOTIFIED: 2-0 I's TIME: 7:00.KA-• <br />D. RFSPOJ`iSiRi.F, PF.RSCIN/R[J4JNFSG <br />NAME OF BUSINESS: <br />Gkij"_yV.17 a 1- &A' a.AA AA <br />CONTACT PERSON: <br />8i �� C�-� <br />PHONE: <br />PHYSICAL ADDRESS: <br />MAILING ADDRESS: <br />5ZA <br />. I <br />F._ DF.SC`RJPT[{�N <br />TYPE OF DISCHARGE: <br />VOLUME: <br />i rp n4 l api. <br />CHEMICALS: <br />a-G,v.R <br />CIRCUMSTANCES: <br />FF..7 ACTION TAKEN U <br />ktt x- &4 SA 4 4 <br />(aa sLimv. S ^A <br />- SITE DISPOSITION <br />SMA.. -:;I;LL IX4 eau/H o / "dV-m' 0— <br />At -rA <br />*&A <br />face f mt�4 <br />n . -. , _ It . <br />PROP 65 C I Revised 07/27/12 <br />