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�O,.PgU�N•.C� SAN JOAQUIN COUNTY <br /> � � Q <br /> i'•.: •`'?a ENVIRONMENTAL HEALTH DEPARTMENT <br /> ?` 600 East Main Street Stockton - CA 95202-3029 <br /> (209) 468-3420 - Fax: (209) 464-0138 - Web: www.s ' ov.org/ehd �l O <br /> �IFatRN <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARG <br /> A. EMERGENCY LEVEL X t u m EHD LOG# ! <br /> B. SOURCE OF INFORMATION <br /> NAME: r7b Y/ C-" r. c-- r GIIvnn I G W PHONE: q QoZ'O3✓73 <br /> COMPANY: CITY: <br /> ADDRESS: 7 S5- <br /> DESIGNATED <br /> 5- <br /> DESIGNATED EMPLOYEE NAME: �`••C PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: <br /> Bert PhyaimlDacrip�ion 77 3 S- <br /> Unincorporated <br /> DATE OF DISCHARGE: ( (q yw a <br /> DATE NOTIFIED: ( q(Z.o(o . TIME: q : (o <br /> a <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> -;' <br /> NAME OF BUSINESS:CONTACTPERSON: PHONE: <br /> PHYSICAL ADDRESS: <br /> MAILING ADDRESS: <br /> 2-7#6 -ngd Q(d fw o <br /> E. DESCRIPTION Q�,,,, /(�� <br /> TYPE OF DISCHARGE: V•eg--Q S pit <br /> VOLUME: <br /> CHEMICALS: r,�T <br /> CIRCUMSTANCES: S&; ' +l f-f—d � (}%,*ya: b-e a m <br /> F. ACTION TAKEN <br /> Cl eaN Gavrip cadip-d f0 stank &pb" a- 5drW4-f- 60014S <br /> p(ited prv" �. C-le� ®F scle in � <br /> ervBrcs- <br /> SITE DISPOSITION <br /> E t+r> *, 'a Caw C. 6-m 4-j,,,,,,P IL L&-ra-sfe <br /> As 3 P o>ss-P <br /> ER RECORD MODIFIED Revised 05/01/2007 <br />