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s <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARG <br /> 4:(o Py <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Terry Ynghi nka Phone: (209) 468-3420 <br /> Company: San Joaquin County Environmental Health SPrvi c-Pc <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: Environment-al HPaI th <br /> Address: 445 N. San Joacmin Stockton <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 4315 E . Waterloo Road Stockton, CA 95205_ Srorktnn <br /> (Best Physical Description) (Ci or County) Circle One <br /> Date of Discharge: Tnkno-un <br /> Date Notified:12/07/94 Time: 2 • 00 Pm <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: Shell Service Station (Shell Oil Company) <br /> Contact Person: Jeff Granberry Telephone: tLO 675-6145 <br /> Physical Address: 1 -390 Willow Pass Riad ,5,,, to 9-0nT gnGord, (;A91i524 <br /> Mailing Address: same <br /> E. DESCRIPTION <br /> Type of Discharge: Fuel release from underground storpaP tank R�7RtPm <br /> Volume: Unknown <br /> Chemicals: Gasoline <br /> Circumstances: Unknown, release discovered during system removal . <br /> F. ACTION TAKEN_ System removed and tank excavation sampled . <br /> SITE STATUS UST contamination wi11 be documented wi th TTAR and gdcipci <br /> to contaminated site database . Further investigation and remediat DD—may <br /> e required by EH and/or CVRVIOCB <br /> EH 22 013 (Rev.4/91) <br />