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?� roc SAN JQUINCOUNTY _ <br /> ENONMENTAL-HEALTH DEPARTI✓� NT <br /> t4 � - <br /> r. 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br /> P. (209)468-3420•Fax: (209)464-0138 • Web:www.co.san-joaquin.ca.us/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 25180.7 <br /> EHD LOG#: <br /> A. EMERGENCY LE I II III <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: a' ) �►�GVI/t Phone: ( ) <br /> Company: <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: I / Ci or Counfy <br /> (Best Physical Description) Circle One) <br /> Date of Discharge: 01 Date Notified: Id-7 Time: "'2 : <br /> A.M. P.M. <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 1 n 3 <br /> Contact Person: Phone: k 5r]G/-�� <br /> Physical Address: J5n1 P4City: �A/1 Zip Code: q5- 3(o <br /> Mailing Address: City: Zip Code: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: GSA <br /> Chemicals: -h%�2('/ <br /> .Circumstances: 1.! 1x1 f'14G! lh pGU" ►�P2 I0 — h QQj OU4 <br /> rle018 a(ph <br /> - <br /> F. ACTION TAKEN: p L4-1 6 yl <br /> w4f ' <br /> v � <br /> E DISPOSITION: <br /> EHD 22-02-003 Notification of Haz Discharge <br /> 10/2/2003 <br />