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SAN JoAQu tRTM T <br /> ° <br /> ENVIRONMENTALHE -2708 <br /> 304 East <br /> WONME <br /> = i Q $lCA 9�2 <br /> ` Weber Avenue,3 d Floor, Stockton, <br /> 209)468-3420•Far. (209)464-0138 - tl`eb:Nv%v'v.cosan-joaqu n.ca.us/ehd <br /> 9 'so <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 25180.7 <br /> �J EHD LOG#: Qq p3 <br /> A. EMERGENCY LEVEL: 1 (cuII One)� <br /> B. SOURCE OF INFORMATION Phone: ( ) --- <br /> Name: <br /> Zip Code: <br /> Company: City: <br /> Address: <br /> Designated Employee Name: Zip Code: <br /> Reporting Agency Name: City: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE ` 4 J;E� .1 CA City or ounty <br /> 2 5 (C ucie Un <br /> r— <br /> Location: (gest Physical Description) <br /> Time. <br /> Date Notified: (0 Iva O <br /> So <br /> Date of Discharge: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Ali. Phone: ( ) Z <br /> Name of Business: ��L�� —Zip Code: <br /> Contact Person: 'avl ity <br /> Physical Address: <br /> C : Zip Code: <br /> ity: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: -------- <br /> Chemicals: <br /> --Chemicals: v N <br /> Circumstances: <br /> g, ACTION TAKEN: "' <br /> i <br /> SITE DISP'OSI 1'"11 <br /> U <br /> N,'elificaridn of Haz Des <br />