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EASAN JOAQUIN COUNTY <br /> ONMENTAL HEALTH DEPART� <br /> MENT r <br /> 304 East Weber Avenue, 3a Floor, Stockton, CA 95202-2708 <br /> ° a (209)468-3420 •Fax:(209)464-0138• Web:www.co.san joaquin.ca.us/ehdf 1 L <br /> q< doa� <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 25180.7 <br /> C0002.52.5Z EHD LOG#:-_0(0 <br /> A. EMERGENCY LEVEL: U III <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: fautl &",, Phone: <br /> Company: ✓ <br /> Address: aV City: c Zip Code: �SLb(P <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: City: Zip Code: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: jgl'tyay! uY• "� / �Ci rCounty <br /> —� (Bes�ystc 1 escription) (Circle One) <br /> Date of Discharge: l0 Date Notified: 0 Y Time: W01 (9. P.M. <br /> D. RESPONSIBLE PERSONBUSINESS <br /> Name of Business: WW N111YQdyl <br /> Contact Person: Phone: (/�p�) (t��1$h9 <br /> Physical Address: Vq ity: WWWA Zip Code: R 520V <br /> Mailing Address: t City: 1 Zip Code: " <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: u <br /> Chemicals: <br /> Circumstances: C&A o <br /> F. ACTION TAKEN: gpAyQ -W Dtoe PYIMM v VF_-F da1Vi �'A< Agkjf <br /> SITE DISPOSITION: i oc4ow S0,11 a myt e,y rat' <br /> OMA is <br /> EHD 22-02-003 Notification of Haz Discharge <br /> 10/2/2003 <br />