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SAN JOAQUIN COUNTY �. <br /> Z ENVIRONMENTAL HEALTH DEPARTMENT <br /> y { 304 East Weber Avenue, 3'd Floor, Stockton, CA 95202-2708 <br /> (209)46S-3420•Fax:(209)464-0138 • Web:w,.v,,v.cb.san-joaquLn.ca.us/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 25180.7 <br /> EHD LOG#: <br /> A. EMERGENCY LEVEL: I II III <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: ( ) <br /> Company: <br /> Address: City: Zip Code: <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: City: Zip Code: <br /> C. LOCATION AND DATE OF DISCHARG (�� <br /> Location: 0 / Cit or ount� <br /> (Be hysical Description) (Circle <br /> Date of Discharge: l Date Notified: Time: <br /> D. RESPONSIBLE PERSONBUSINESS <br /> Name of Business: S <br /> Contact Person: Phone: ( ) <br /> Physical Address: 1 ity: � Zip Code: q5 2,12— <br /> Mailing <br /> Mailing Address: City: Zip Code: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN: <br /> SITE DISPOSITION: <br /> r 11 <br /> E-N-1n Y <br /> Notification or Haz Discharp <br /> EHD 22-02-003 <br /> 10 212003 <br />