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. trSAN JOAQUIN COUNAENVIRONMENTAL HEALTH DEPARTMENT <br />fes\ <br />600 E. Main Street Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Far.- (209) 468-3433 Web. www.sjgov.0 <br />NOTIFICATION OF EUZARDOUS WASTE i 4." <br />Caffornin HeWth & Safety Code,i25180.7 <br />EHD LOG 1 i <br />A. EMERGENCY LEVEIO 11 111 <br />O, <br />B. SOURCE OF i i <br />Phone:/ i <br />Address:City: Zip Code: <br />Designated Employee Name: <br />Reporting Agency Name: <br />Address: City: Zip Code: <br />C. LOCATION AND DATE OF DISCHARGE <br />Location: _3 22/i or County <br />(Bost Physical Description) (Circle One) <br />Date of Discharge: —) t? ® Date Notified: G't Time: 6;07- n.m. BMJ <br />D. RESPONSIBLE PERSON/BUSINESS <br />Name of Business: QrItrge.. C 4) 7AZO <br />Contact Person: I k t e j Phone: ( } N <br />Physical Address: NG QM Air• City: AgNk4. CA Zip Code: <br />Mailing Address: Y City: Zip Code: tt <br />E. DESCRIPTION <br />Type of Discharge:. �p j <br />Volume: <br />Chemicals: i <br />Circumstances: V e G, t L CR., -Pye, %- t 4411 <br />F. ACTION TAKEN: _ 7,-�,, Sri i A .1`1 . F n <br />0 <br />EHD 22-03 Notification of Haz Discharge <br />11/26/2007 <br />