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' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton •CA 95202-3029 Fly, .. , <br /> (209)468-3420•Fax:(209)464-0138 • Web:www.s{Qov.or /g ehd 1��1 <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL I X I II III EHD LOG# <br /> B. SOURCE OF INFORMATION <br /> NAME: PHONE: fp <br /> COMPANY: CITY: <br /> ADDRESS: WD :U� . <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: �AHX <br /> CITY � , Inco rated <br /> Best Physical Description � Unincorporated <br /> DATE OF DISCHARGE: 1 (9- <br /> (� <br /> DATE NOTIFIED: it s a TIME: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: 't-"10Yjee4 S PC lJ►f�'1 ✓�l y�r r� <br /> CONTACT PERSON: PHONE: <br /> PHYSICAL ADDRESS: S . 3 <br /> MAILING ADDRESS: <br /> E. DESCRIPTION 1 ' <br /> TYPE OF DISCHARGE: 'Ic/1/ <br /> VOLUME: <br /> CHEMICALS: D <br /> CIRCUMSTANCES: Y dl (�- <br /> F. ACTION TAKEN <br /> Sp IM X t�- Jt t <br /> 00(11� Ibbs <br /> I <br /> t SITE DISPO1SIITION�` I <br /> ER RECORD MODIFIED Revised 05/01/2007 <br />