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SAN JOAQUIN COUNTY ✓ O <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILE <br /> PY <br /> 304 East Weber Avenue, 3d Floor, Stockton,CA 95202-2708 <br /> r (209)468-3420-Fax:(209)464-0138 . iV_eb:w�Jwxo.sanjoaquinxa.us/ehd <br /> o N <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 25180.7 <br /> EHD LOG#: 04 — 0 ,77- <br /> A. EMERGENCY LEVELC U III <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> J <br /> 3' <br /> Name: (Wo <br /> Company: N <br /> Address: 2 City: 1S {�Gc� ><n� Zip Code: AZO Z <br /> Designated Employee Name: C I <br /> Reporting Agency Name: I <br /> 1 I City: Zip Code: <br /> Address: <br /> C. LOCATION AND DATE OF I 2ARGE <br /> Location: AIA JCC / / Cit r Count <br /> - <br /> (Best Physic Description) / ircle One) <br /> Date of Discharge: �� /��I a 7nDate Notified: ( �z Z�4 Time: <br /> D. RESPONSIBLE PERSON/BUSINESSA n <br /> Name of Business: �C' a>`J ��P a <br /> _j <br /> Contact Person: C Phone: ( ) <br /> Physical Address: c� , �,5/City: oc caw Zip Code: <br /> Mailing Address: I/ City: Zip Code: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: l` <br /> c3-s� u <br /> F. ACTION TAKEN: <br /> SITE DISPO ITION: <br /> Z•• <br /> 1 Notification of Haz Discharge <br /> EHD 22-02-003 �� t ��-b-V �Cl�� `��( �/�(��l• <br />