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• SAN JOAQUIN COUNTY• <br /> op,4Y.!N..CO <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> R a <br /> "? x 304 East Weber Avenue,3`d kloor,Stockton,CA 95202-2708 <br /> (2 09)468-3420•Fax:(209)464-0138 iVeb:wv�w.cO.san-joaquin.ca.us/elid <br /> 9C FORS <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 25180.7 <br /> EHD LOG#:05_ L <br /> A. EMERGENCY LEVEL: (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: (611) X33 �?4�� <br /> Name: <br /> Company: 1 y <br /> _Cit / 1 -.Ir y (��_Zip Codes <br /> Address: <br /> Designated Employee Name: <br /> Reporting Agency Name: City: Zip Code: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE Cit or Count <br /> Location' Circle One) <br /> (Best P ical Description) <br /> Date of Discharge: l A ti k^^''"`� Date Notified: t 4 <br /> Time:��;3�a" <br /> D. RESPONSIBLE PERSONIBUSINESS <br /> Name of Business: Phone: V042!�b2 tir <br /> al. <br /> Contact Person: City: Zip Code: <br /> pu <br /> Physical Address: St Cit �/ C*• Zip Code: 9S�9 <br /> Mailing Address: b l W °SIe�M u y' <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> afar <br /> 7 ,.f. e.CA/ � <br /> Chemicals: <br /> Circumstances: 73u <br /> F. ACTION TAKEN: U e0 e � <br /> alk- <br /> SIT fDP S[TION-. S waai� <br /> Notification or Haz Discharge <br />