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o '& l SAN JOAQUIN COUNTY <br /> { ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3d Floor, Stockton,CA M02-2708 <br /> r (209)468-3420•FaY:(209)464-0138 • Web:www.co.san-joaquin.ca.us/chd <br /> 2 p µN <br /> 0TIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section <br /> 251180.7 <br /> COPYEHD LOG#:[��MERGENCY LEVEL Il III <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (971&) b - 01 (o? <br /> Company: <br /> Address: L�l���"'- RteQc>c. Ci Zip Code:9�R2g <br /> Designated Employee Name: �� <br /> Reporting Agency Name: <br /> Address: City: Zip Code: <br /> C. LOCATION AND DATE I,O. F�_DISCHARGE <br /> S k9rAl- 6AIP City or <br /> Location: /b 9Y Z ou _ <br /> (Best Physical Description) (Circle <br /> �7 . <br /> Date of Discharge: b�' J' Date Notified: -�(r o O Time: A.M. P.>1 <br /> D. RESPONSIBLE PERSONBUSINESS <br /> Name of Business: f< <br /> Contact Person: eti/ Phone: (�pq) <br /> Physical Address: [(2 Ad- City C& G Zip Codel I <br /> Mailing Address: P box I V 69 CiZip Code:`Fa'71 <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: Z <br /> Circumstances: <br /> S <br /> F. ACTION TAKEN: e �'��� w�- <br /> s - <br /> SITE DISPOSITION: 1413 <br /> a. <br /> A40 44 7-- <br /> IAI <br /> .LuJ. <br /> it Q i <br /> Notification of 1W ITxharge <br /> cin 11J7.Mi <br />