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SAN JOAQUIN COUNTY p D <br /> ?� ENVIRONMENTAL HEALTH DEPARTMENT <br /> l 600 East Main Street Stockton • CA 95202-3029 <br /> (209)468-3420•Fru:(209)464-0138 • Web:www.sigov.org/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL x I II III EHD LOG# 1 12 ,63�� <br /> B. SOURCE OF INFORMATION <br /> NAME: p'G•Ol/ G�"•n�/•M�tAIAc PHONE: CJit_G17-16 a <br /> COMPANY: G•tl w+ i\-GC 0 '1 �1 / CITY: S�OV1G Cp�� <br /> ADDRESS: S kxt--) P-6� <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: Z 33.S CITY Ql p f_y� V Incorporated <br /> Best Physical Description <br /> Unincorporated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: TIME: ^'�Jti'�^� <br /> D. RESPONSIBLE PERSON/BUS ESS <br /> NAME OF BUSINESS: -ff%\ - <br /> CONTACT PERSON: L • PHONE: U� !<i►�t <br /> PHYSICAL ADDRESS: -naACA 17 57 <br /> MAILING ADDRESS: 33 <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: am <br /> VOLUME: k1a ILK/ <br /> CHEMICALS: /J n <br /> CIRCUMSTANCES: <br /> F. ACTION TAKEN _ <br /> t SITE DISPOSITION <br /> .fib t� aid <br /> VA44&"0144 <br /> ..l�� �'� �, /�►.au� Gu►e� �G�� � CO�.�tu� /ltita_y-YrC, <br /> Q dk� <br /> U� <br /> FR RI Y ORD MODIFIED Revised 05/01/2007 <br />