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SAN JOAQUIN COUNTY /7 <br /> /� .co <br /> y „ '?1 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 1 00.4 <br /> `cZl (209)468-3420-Fax:(209)464-3433 • Web:www.sigov.org/ehd <br /> roR`' <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL 01 ❑ it ❑ 111 EHD LOG# -p 2 <br /> B. SOURCE OF INFORMATION <br /> NAME: �a, (.i I cc. ct; PHONE: <br /> i <br /> COMPANY: San Joaquin County Environmental Health Department CIN: Stockton <br /> ADDRESS: 1868 E. Hazelton Ave. <br /> DESIGNATED EMPLOYEE NAME: Y w%11 �' PHONE: <br /> REPORTING AGENCY NAME: San Joaquin County Environmental Health Department <br /> ADDRESS: 1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: (9—Cr (' n c 'v,4i ❑ Incor orated <br /> Best Physical c I � G.•, CITY <br /> Description 2� 7"7 �% ?vFi � ".- =©� Unincorporated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: TIME: cj <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: _ ar R'- C <br /> CONTACT PERSON: �. 7 _ lrl/ T tic .l x y PHONE: <br /> PHYSICAL ADDRESS: an?r' <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: A j y c"J JfiJ Gt��tur�Q�. G trr'i� '/t�1r��i�r 7Y"i l,a9 ✓ �1p _ v �C� <br /> VOLUME: n✓r- Jr L..�. ( :2w✓ t1L (� i �- 1 ��?.,— <br /> CHEMICALS: <br /> I <br /> CIRCUMSTANCES: v�.vY�n�� g(j�.S✓ L'A/' •TTtt (�7�%t�+f f I rP. ��;r/ScGjc�T��'_ , <br /> F. ACTION TAKEN )J II <br /> y r <br /> SITE DISPOSITION <br /> 111,267 <br /> Revised 08/02/12 Page 1 of 2 NOTIFICATION OF HAZ WASTE DISCHARGE <br />