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° SAN JOAQUIN COUNTY � � � � � Q <br />c <br />ENVIIZONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3'a Floor, Stockton, CA 95202-2708 <br />� P° a <br />P (209) 468-3420 • Fax: (209) 464-0138 • Web: w*w.co.san-joaquin.ca.us/ehd <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />California Health & Safety Code, Section 25180.7 <br />EHD LOG #: O(o -0 -4 3 <br />A. EMERGENCY LEVEL:; 1 II III <br />l/ (Circle One) <br />B. SOURCE OF INFORMATION <br />C. <br />EQ <br />E. <br />F. <br />Name <br />Company: VQ -"w i <br />Address: <br />Designated Employee Name: <br />Reporting Agency Name: <br />City: <br />Address: City: <br />LOCATION AND DATE OF DISCHARGE <br />Location: <br />(Best Physical Description) <br />Phone:) ql%%`�25 <br />Zip Code: <br />Zip Code: <br />One) <br />Date of Discharge: 1 (a 10(o Date Notified: b t Time: `7 zFi t P.M. <br />RESPONSIBLE PERSON/BUSINESS <br />Name of Business: <br />Contact Person: <br />Physical Address: <br />Mailing Address: <br />DESCRIPTION <br />Type of Discharge: <br />Volume: <br />Chemicals: <br />City: <br />Phone: (201 <br />Zip Code: <br />Zip Code: <br />EHD 22-02-003 Notification of Haz Discharge <br />10/2/2003 _ <br />