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o?`'":.'N..c SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street Stockton • CA 95202-3029 <br />k ` (209) 468-3420 • Fax: (209) 464-0138 • Web: www.sigov.org/ehd <br />��FORa <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />A. EMERGENCY LEVEL 1X1'I I'lllu EHD LOG# <br />R_ SOi TRC;F.-OF INFORMATION <br />NAME: <br />f ew- ih >m Lr, 6k&- .il � <br />CONTACT PERSON:/` <br />PHONE: <br />PHONE: <br />COMPANY: <br />PHYSICAL ADDRESS: <br />CITY: <br />MAILING ADDRESS: <br />ADDRESS: <br />DESIGNATED EMPLOYEE NAME: <br />PHONE: <br />REPORTING AGENCY NAME: <br />ADDRESS: <br />C LOCATION AND DATE OF DISCHARGE <br />LOCATION: �AHW <br />/�� CITY Incorporated <br />Best Physical Description ( ), /I / th, V'� �—�- Unincorporated <br />DATE OF DISCHARGE: IS 1-0 <br />DATE NOTIFIED: Il s TIME: (� <br />D RESPONSIBLE PERSON/BUSINESS <br />NAME OF BUSINESS: <br />f ew- ih >m Lr, 6k&- .il � <br />CONTACT PERSON:/` <br />&1424 �i/ <br />PHONE: <br />�a <br />PHYSICAL ADDRESS: <br />or2b 3-6tAjitct5 <br />MAILING ADDRESS: <br />T T T'. V 11" TTYTTlIAT <br />TYPE OF <br />i7,t-: <br />CIRCUMSTANCES: <br />On <br />P ACTU)N TAKEN <br />g1rrP T)T.CPO.gTTTnN <br />ER RECORD MODIFIED Revised 05/01/2007 <br />