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SAN JOAQUIN COUNTY <br /> _ cy ENVIRONMENTAL HEALTH DEPARTMENT <br /> y 304 East Weber Avenue,3rd Floor, Stockton,CA 95202-2708 <br /> .......... (209)468-3420•Fax:(209)464-0138• Webr www.co.san-joaquin.ca.us/ehd <br /> �� FORN <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 INF9,RMATION <br /> i-� Phone: q S Z dl 1 <br /> Name: 4� ( C� ) <br /> Company: CJ CO� <br /> , Address: 1 D G-1 old 1 l lei r. Suiity: vtCor doycL Zip Code: q- <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: 3d(+ VUP (oQ✓ City: 9Sto fon Zip Code: -520 Z <br /> C. LOCATION AND DATE OF,DISCHARGE Iw <br /> Location: _ y V �t X'��'` V C V (Cit r Count <br /> (Best Physical Description) ircle One) <br /> Date of Discharge: � I C_0 0,JA Date Notified: (� � 121200f Time: A.M. P." <br /> Qppar� Qe-ce�� <br /> D. RESPONSIBLE PERSONBUSINESS <br /> I f <br /> Name of Business: v A - r� <br /> Contact Person: Phone: (1 16) <br /> Physical Address: q45( AJ i 06� C:: ' City: g,s P%j" Zip Code: 95 f} <br /> Mailing Address: A S Algvy6 City: Zip Code: <br /> E. DESCRIPTION <br /> Type of Discharge: U IVAUTkoRI-z�D t C-.A <br /> Volume: U N Y-MaLA)N <br /> Chemicals: PC ar <br /> Circumstances: t ►'r te 40 A <br /> F. ACTION TAKEN: <br /> Ix <br /> r <br /> r <br /> SITE DISPO I ION: �e <br /> r ✓ /L LO <br /> Notification of Haz Discharge <br /> EHD 22-02-003 <br /> 10/2/2003 <br />