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rn�,;° <br /> SAN JOAQUIN COUNTY - <br /> I ENVIRONMENTAL HEALTH DEPARTMENT <br /> INA '= 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420 • Fax:(209)464-3433 • Web:www.siaov.orci/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL ❑x 1 ❑ II ❑ III E H D LOG# (��- <br /> B. SOURCE OF INFORMATION_ <br /> NAME: _ _ _ � �i -'� 3 PHONE: JIB <br /> COMPANY: San Joaquin County Environmental Health Department CITY: Stockton <br /> ADDRESS: 868 aze On ve. <br /> DESIGNATED EMPLOYEE NAME: ej() i)XV) PHONE: 1 -,2-0c(-Cc <br /> REPORTING AGENCY NAME: San Joaquin County Environmental Health Department <br /> ADDRESS: 1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: `l ❑ Incorporated <br /> Best Physical 14 )-z!)q tveotoA pzCITY <br /> 1 <br /> Description 6 � Unincorporated <br /> DATE OF DISCHARGE: �jntr` ouer) <br /> DATE NOTIFIED: —D•o I TIME: WIAS aV%A-1 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: Sal I zar -R , \ , lb,( G,Ld \,oLZ <br /> CONTACT PERSON: ` ^ PHONE: I WC1- <br /> PHYSICAL ADDRESS: �-� Q N ' • wl Az(�- ` CA <br /> MAILING ADDRESS: I�� Le l . �2 <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: t_►4_ <br /> VOLUME: OR Vn ow NL- <br /> CHEMICALS: <br /> CIRCUMSTANCES: OVk"Y) "� otti e cpoVx CA <br /> F. ACTION TAKEN <br /> v �.Cv"TI-t�+Y1 ' UA ' <br /> SITE DISPOSITION L <br /> w WbL�+e (�,kQkw-\,tf Gtvv6 <br /> Revised 08/02/12 Page 1 of 2 NOTIFICATION OF HAZ WASTE DISCHARGE <br />