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�o <br />SAN JOAQUIN COUNTY D <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />u): <br />600 East Main Street Stockton - CA 95202-3029 <br />• c ', (209) 468-3420 • Fax: (209) 464-0138 • Web: www.sigov.or /e�hd !�a <br />NdTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />A. EMERGENCY LEVEL I x I II III <br />B. SOURCE OF INF RMATION <br />EHD LOG# J -0 <br />NAME: <br />e, <br />CONTACT PERSON: <br />PHONE: <br />PHONE: <br />COMPANY: <br />tk?' <br />CITY: <br />of <br />ADDRESS:2�23 <br />� . <br />DESIGNATED EMPLOYEE N <br />E: <br />PHONE: <br />�7 <br />REPORTING AGENCY NAME: <br />ADDRESS: <br />C. LOCATION AND DA E OF DISCHARGE <br />LOCATION:n� I ,�j CITY Incorporated <br />Best Physical Description <br />Unincorporated <br />DATE OF DISCHARGE: ' <br />DATE NOTIFIED: TIME: •.� <br />n RT:QPlINQTRT T: PRT?Q N/RTlQTNT:QQ <br />NAME OF BUSINESS:Vf <br />CONTACT PERSON: <br />S <br />PHONE: <br />99 <br />(O <br />PHYSICAL ADDRESS: <br />MAILING ADDRESS: <br />of <br />F DFSCRTPTION <br />TYPE OF DISCHARGE: <br />VOLUME: <br />S <br />CHEMICALS: <br />CIRCUMSTANCES: <br />F. ACTION TAKEN <br />Ufa /Wtwfi�L� <br />SITE DISPOSITION <br />ER RECORD MODIFIED I Revised 05/01/2007 <br />M\t <br />