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SAN JOAQUIN COUNTY I' <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />( 09) 468-3420 • Fax: (209) 464-3433 • Web: www.siaov.or-q/ehd <br />NOTIFICATION OF AZARDOUS WASTE DISCHARGE <br />A. EMERGENCYEVEL ❑x 1 El El III EHD LOG# /-;5 —(j 9C/ <br />R qnl iprp: nF' IN nR1 AAMN <br />NAME: <br />{� <br />'� '^��A <br />b' (4 S+ <br />PHONE: <br />COMPANY: <br />��� <br />pal T,0[, r'�`� nt CITY- Stockton <br />Ar �' <br />ADDRESS: <br />DESIGNATED EMPLOYEE NA <br />E: <br />rs Ap- 41 �� all q r1,7�i j, Nh6(.Z4'v�-vtf su Kcg - o� its . <br />W I� f�� n -{-&1V1V- ytao�d - <br />PHONE: <br />TIME: <br />REPORTING AGENCY NAME: <br />San Joaquin County Environmental Health Department <br />ADDRESS: <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />f` I nrATlnnl Amf nATF nF nlRf'HARC;F <br />LOCATION:�(� <br />Best Physical <br />Description <br />{� <br />'� '^��A <br />b' (4 S+ <br />CITY <br />' <br />Incorporated <br />❑ Unincorporated <br />DATE OF DISCHARGE: <br />MAILING ADDRESS: <br />910 (J <br />DATE NOTIFIED: <br />rs Ap- 41 �� all q r1,7�i j, Nh6(.Z4'v�-vtf su Kcg - o� its . <br />W I� f�� n -{-&1V1V- ytao�d - <br />G--eto-j r3 <br />TIME: <br />n PP.gPnN.qIRI FIPFRRnN/RIIRINFRR <br />NAME OF BUSINESS:I <br />CONTACTPERSON: <br />Pv/ QC[QU 90�l <br />PHONE: <br />26 <br />PHYSICAL ADDRESS: lia <br />S} <br />MAILING ADDRESS: <br />CIRCUMSTANCES: <br />F nFCrRIPTInN <br />TYPE OF DISCHARGE:Gt�eetZ(6 <br />VOLUME: <br />V <br />``'' <br />6M C �y n , n."b `o6 (w' <br />CHEMICALS: <br />r&sel <br />CIRCUMSTANCES: <br />5 <br />rs Ap- 41 �� all q r1,7�i j, Nh6(.Z4'v�-vtf su Kcg - o� its . <br />W I� f�� n -{-&1V1V- ytao�d - <br />F. ACTION TAKEN <br />arm cVf-s-Qt qilEoga �§ oaf-LAad �vl <br />Nay pai <br />SITE DISPOSIT ON <br />,� �a <br />Revised 08/02/12 1 Page 1 of 2 NOTIFICATION OF HAZ WASTE DISCHARGE <br />