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'• PpU1N <br /> SAN JoAQuiN CouNTY awCp <br /> Z` ENVIRONMENTAL HEALTH DEPARTMENT <br /> y: C <br /> 600 East Main Street Stockton •CA 95202-3029 <br /> P (209)468-3420•Far:(209)464-0138 • Web:www.s' ov.or e <br /> `C � <br /> 9ClFORN <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL I x I I EHD LOG# <br /> B. SOURCE OF INFORMATION <br /> NAME: f R m,4;, 1 PHONE: Dd'-?g 7-772 <br /> COMPANY: 'f r e, 4- CITY: arsi�ro N C <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF(rjDISCHARGE /� �L� <br /> LOCATION: (.�/yc�' /v � � <br /> c GL Ttv�-, CITY Inco rated <br /> Be enysiw Dmripim J/�H <br /> Unincorporated <br /> DATE OF DISCHARGE: 'a-5 1cJ <br /> DATE NOTIFIED: © p TIME: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: v.+q <br /> CONTACT PERSON: PHONE: S� y' 6 <br /> PHYSICAL ADDRESS: 64-2e�-A <br /> MAILING ADDRESS: 4. <br /> E. DESCRIPTION / <br /> TYPE OF DISCHARGE: 5;7, r/ <br /> VOLUME: q o,-_f <br /> CHEMICALS: o <br /> CIRCUMSTANCES: •H ta./q 9S �S l [.SSV l �-c.Y S' I J� -5� oc� <br /> F. ACTION TAKEN <br /> �./'/�� a7�c�� l/+S PAX t, Ds ar6r�-T -�o U¢c,••,,.1 <br /> SITE DI�S`PPOO/SMON�f/�_� 1- <br /> / <br /> ER RECORD MODIFIED Revised 05/012007 <br />