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U SAN JOAQUIN COUNTY FILE COPY <br /> o ' ' '•°o <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ` 304 East Weber Avenue,3`d Floor, Stockton, CA 95202-2708 <br /> (209)468-3420•Fac:(209)464-0138 • Web:www.co.san joaquin.ca.us/ehd <br /> O°CFo'R��P <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, section <br /> EHDLOG#: <br /> � <br /> A. EMERGENCY LEVE ' I II(Circle one) <br /> B. SOURCE OF INFORMATION Phone: (Zm) Llbl�' Ll LiOD <br /> Name: vv\ <br /> Company: �r Zip Code: <br /> City: <br /> Address: <br /> Designated Employee Name: �� <br /> Reporting Agency Name: �, Zip Code: <br /> � City: <br /> Address: <br /> ON AND DATE OF DISCHs• ���4� Cit Countv <br /> C, LOCATI J <br /> [�kRGE <br /> 12b /� (Cir D <br /> Location: <br /> (Best Physical Description) <br /> Date of Discharge: 21 �1-1 "Date Notified: Time: <br /> D. RESPONSIBLE PERSONIBUSINESS (yen enxl.� Ikt/u <br /> SAN °^ ' <br /> Name of Business: Phone: ( ) <br /> Contact Person: G vL Zip Code: <br /> City: <br /> Physical Address: Zip Code: <br /> City: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> C� <br /> ori } � � <br /> F. ACTION TAKEN: <br /> SITE DISPOSITION: <br /> VT Notification of Haz Dischare <br />