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` QUIN COUNTY -/ <br /> OG <br /> r ti ENVIRONMENTAL HEALTH DEPARTMENT <br /> y 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202-2708 <br /> (209)468-3420•Fir:(209)464-0138 - IVA:w%;-%v.co,san-joaqujn,ca.us/6d <br /> c4LlFORA <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 25180.7 <br /> EHD LOG#: d 4- <br /> A. EMERGENCY LEVEL-A) II III <br /> (Circle One) <br /> B. SOURCE OF INFORiMATION <br /> Phone: (909) (p <br /> Name: <br /> Company: $ S}1(c Y <br /> Address. Cit�3rf��_ 1 _Zip Code: �5 215 <br /> Designated Employee Name: _�l 0- e Vj <br /> Reporting Agency Name: n <br /> Address: City: Zip Code: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> O � t•� Ci r County <br /> Location: ucie One) <br /> est Physical Description) _ , <br /> Date of Discharge: klD WYL Date Notified: 5 J—b4 Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> !Fame of Business: I %.-"1t�' <br /> Contact Person: Phone: (M ) qN3�— <br /> Physical Address: <br /> City: Zip Code: q5�1� <br /> Mailing Address: City: Zip Code: <br /> E. DESCRIPTION <br /> Type of Discharge: _ 64- � <br /> Volume: <br /> Chemicals: <br /> Circumstances: Q <br /> F. ACTION TAKEN: vt <br /> SITE DISPOSITION: t_7`p <br /> Notification ofHaz DischarV <br />