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TO 19167e67e3O P 02 <br />' 04-11-1995 08 01AM FROM <br /> SAN 30AQULN COUNTY J) <br /> NOTIFICATION OF HAZARDOUS WASTE DISCH RGH,�cc, <br /> HEALTH & SAFETY CODE 25180.7 Y <br /> 1 , <br /> EMERGENCY LEVEL II III PHS-EH LOG # �" l 71V <br /> ( cie Oue) <br /> B. SOURCE OF INFORMATION <br />' Name:_ T��--r-�� � Phone. (209) 4�8--342_Q_ <br /> Company: San Joaquin County Env- <br />' Address: <br /> Designated Employee Name: Phone: L� <br /> Reporan,a Agency Name:Eny z:n1 tznz1 Health <br /> Address: 445 NI San Joao-din Stockton <br /> 1 <br /> C. LOCATION AND DANE OF DISCHARGE <br />' Locaaon: 4315 E . ,Vaterloo Road Stockton , <br /> (Best Physical Descripdon) Ci or County) Circle One <br /> Dare of Discharge: <br />' Dare NodEed.12/07`,/94 Time* 2 - 0 n <br /> D. RESPONSIBLE PERSQNBUSINESS <br /> Name of Busyness: Shell Service Station (Sh911 01 1 C _ <br /> Contact Person: J e`lf f Granberry Telephone: XILO 6 7 5-61/L 5 <br /> Physical Address: p _ . n _ <br />' Marling Address: same <br /> DESCRIPTION, <br /> Type of Dyscharge: Fuel rele se rrom dP.xd aundKram-?- tan S3=s.ie*r+ <br /> Volume. 3 Unknown <br /> Chemicals: Gasoline <br />' Circvrnstances:,_Unknown, release discovered du-ring system removal— <br /> ACTION TAEC&N____ tem removed and tank excavation-samplad ._. <br /> SITE STATUS UST 'contami anon will hp dnc-tnrprrP _jgil-h TTAR aM <br /> to contaminated site database Further investi _ t on and -iay <br /> e requirea by H'Ei an /or CWHOCE <br /> L'22 013 (Rev 4/91) <br />