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>° 4U SAN JOAQUIN COUNTY <br /> ENAWNMENTAL HEALTH DEPARTML11T d <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202-2708 <br /> ° P (209)468-3420•Fax: (209)464-0138 • Web: www.co.san-joaquin.ca.us/ehd <br /> q<IFO�� <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 25180.7 <br /> EHD LOG#: CC? — 0 c7 T <br /> A. EMERGENCY LEVEL I II III <br /> (Circle One) <br /> B. SOURCE OF FORMATIO <br /> Name: <br /> Company: <br /> Address: 514A.C..J Ciityy:,e Zip Code: S -15 <br /> Designated Employee Name: �. fe-��- 20G . <br /> Reporting Agency Name: <br /> Address: City: Zip Code: <br /> C. LOCATION//AND DATE OF DISCHARGE <br /> Location: sw• r County <br /> (Best Physical Description) ircle One) <br /> Date of Discharge: Date Notified: S 7 0 9 Time: <br /> D. RESPONSIBLE PERSONBUSINESS <br /> Name of Business: NQA"Aa e <br /> Contact Person: Phone: ) Q <br /> Physical Address: / ity: sa-e-�4 O_Zip Code: !F:5P15-1 <br /> Mailing Address: !00 / 5*0Y' owd City: Zip Code: T/ <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: 11� <br /> Circumstances: ao <br /> F. ACTION TAKEN: ,d�7- .��W ) <br /> i <br /> SITE DISPOSITION: <br /> a2& !!�� 6 W-4 <br /> EHD 22-02-003 Notification of Haz Discharge <br /> 10/2/2003 <br />