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L _ SAN JOAQUIN COUNTY <br /> EN', 4 ATTAL HEALTH DEPARTN,.gT <br /> 600 E.MainStreet,Stockton,CA 95202 <br /> (209)468-3420■Fay. (209)4644392■ Web;www.e64#0jogqt&ca.us/ehd <br /> 4 NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health:& Safety Come, Section 25180.7 <br /> EHD LOG <br /> A. EERGENG'Y LEVEL <br /> (Circle:;One) <br /> B. SOURCE OF INFORMATION <br /> Nairne.. ,,- - W: <br /> Phone. <br /> �-f <br /> Address: ' d 1a <br /> _. jt .Z-1 City: <br /> Designated Exnployee-Nar e: <br /> Reporting Agency N4Me: <br /> Address: City. Zip Code: <br /> C LOCATION AND BATE Eat'DISCHARGE <br /> Location: 1 lilg 2.2 :5# .+ry., � t Cit or Count <br /> (Best Physical Description) �— (circle One) <br /> Date ofDischarge: -2 "`y- Date Notified: _Time: &M <br /> D. RESPONSIBLE PERSONIBUSINESS <br /> Name of Business: b d <br /> WdqContact person: +` OV ZAh 6 Phone:f <br /> physical,Address: 310 � &- t6&0,,d! zty: v�-� ,Zip Cade: 95`3.3 <br /> Mailing Address: City: Zip Code: — <br /> E. DESCRIPTION <br /> Type of Discharge: M fsce_1141111 ate..+. <br /> Chemicals <br /> Czrctiunstances: ' ,�- <br /> F. AC'T'ION TAKEN: <br /> SITE DISPOSITION: ,-& `4 .. zg kK <br /> EFM 22.02-003 Notificatiotrof Haz Discharge <br /> 05(04107 <br />