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�o au co SAN JOAQUIN COUNTY <br /> ay ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 ast Weber Avenue, 3'd Floor, Stockton,CA 95202-2708 <br /> • <br /> (209)468-.3420 •Fax:(209)464-0138 • Web:w«tiN'•co.san-joaquin_ca.us/ehd <br /> cQ�IF;OR��P <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 2180.7 <br /> EHDLOG#: 63 <br /> A. EMERGENCY LEVEL•( I J II III <br /> �� (Circle One) <br /> B. SOURCE OF INFORMATION <br /> ��L "IIll Phone: ( ) <br /> Name: <br /> Company: Zip Code: <br /> Address: l g- L-2- city:Designated Employee Name: <br /> Reporting Agency Name: Zip Code: <br /> Address: City: <br /> �-g19 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> �L �pt,4 ./ S / it County <br /> Location: Tcie One) <br /> (Best Physical Description) <br /> Date of Discharge: i� b Date Notified: Time: <br /> /2' Tri <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: ) <br /> Phone: <br /> Contact Person: Zi Code: <br /> Physical Address: `�... City: p <br /> Mailing Address: L <br /> �, CityA. <br /> : Zip Code: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> Sy Cz--QLe, ir1Y.•,.._ t <br /> F. ACTION TAKEN: <br /> SITE DISPOSITION: 4 <br /> z <br /> c4� <br /> Notification of Haz Discharge <br /> EHD 22-02-003 <br />