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------------------------------ - ------- <------------------- ------------ -- -------- - -------------------------- --------- <br /> !Z <br /> SAN JOAQUIN COUNTY <br /> „ a ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c P ( 09)468-3420• Fax:(209)464-3433• Web:www.sigov.org/ehd <br /> NOTIFICATION OF AZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL ❑x 1 ❑ II ❑ III EHD LOG# <br /> B. SOURCE OF INFORMATION /� <br /> NAME: 6 VU �./ ;V PHONE: n-`l61 <br /> COMPANY: CITY: <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NA E: PHONE: <br /> REPORTING AGENCY NAME: San Joaquin County Environmental Health Department <br /> ADDRESS: 1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br /> C. LOCATION AN D DATE OF DISCHARGE <br /> LOCATION: lko ki r�tA� Gbf 0� ` Incorporated <br /> Best Physical ('� } 1 /-7�t . 11.q CITY �j1/, <br /> Description 1`l I/� {'-U t N 30 1 ❑ Unincorporated <br /> DATE OF DISCHARGE: ( 1, 0• { t ' 3 <br /> DATE NOTIFIED: `(}- (L ` 1 TIME: <br /> D. RESPONSIBL PERSON/BUSINESS <br /> NAME OF BUSINESS: PIP(b/N ('U <br /> CONTACT PERSON: r ��` '60 PHONE: <br /> PHYSICAL ADDRESS: b S C f6liftla { —h—Jrv; <br /> MAILINGADDRESS: I <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: lbiia <br /> VOLUME: <br /> CHEMICALS: <br /> CIRCUMSTANCES: <br /> F. ACTION TAKE <br /> fW'w 3p U a 6�rtk aatr4 U P &Uf a-tob&�' <br /> v P-0 Gm.�,`� (-10 dean nd Z-[ g d,E' <br /> SITE DISPOSI ION <br /> No J�krk'tr <br /> Revised 08/02/12 Page 1 of 2 NOTIFICATION OF HAZ WASTE DISCHARGE <br />