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SAN JOAQUIN COUNTY <br /> 2 T ENVIRONMENTAL HEALTH DEPARTMENT <br /> y <br /> 304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 • <br /> (209)4 8-3420-Tax:(209)464-0138 . iVeb:%v%inv.co.san-joaquin.ca.us/ebd <br /> qCI FO L <br /> IFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 25180.7 <br /> 9� EHD LOG#: <br /> A. EMERGENCY LEVEL 11 111 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: (2 <br /> Name: <br /> gD5el 13n56 09) SS$- (02,90 <br /> Company: Mfr►..1 Nb eync•'h I -• <br /> Address: <br /> 5"Ou F LavySti 401— City: LA P/' Zip Code:9S330 Designated Employee Name: Von 6�� <br /> Reporting Agency Name: S awc Al �``��/� Zip Code: <br /> Address: City: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> � D�o�� L,Pr '�,ryp • / Citv�rCounty <br /> Location: S 6D (Circle One) <br /> (Best Physical Descnp� <br /> /1- Z`'( <br /> Date of Discharge: (o <br /> Date Notified: �l Z g �� Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 1`J I f Nom) N - A , <br /> ?� SOAJ Phone: <br /> i AD WAA 5 <br /> ( )�— <br /> Contact Person: <br /> Physical Address: YDS L p✓rF` q-vin.- City: G hyP Zip Code: � <br /> Mailing Address: <br /> City: Zip Code: <br /> E. DESCRIPTION <br /> Type of Discharge: e A eOU- <br /> Volume: 1• <br /> Chemicals: tre-ur-sq <br /> Circumstances: J <br /> F. ACTION TAKEN: C I L/k------------------------------- <br /> SITE DISPOSITION: <br /> yp B'1 b I� G(n-•� �� <br /> NoeGcation or Hn Dischs8 <br />