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o o SAN JOAQUIN COUNTY v <br /> c2 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3'Floor, Stockton,CA 95202-2708 <br /> c'°t doad�r <br /> (209)468-3420 Fax:(209)464-0138 • We6r v vw.co.san-joaquin_ca_us/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 25180.7 <br /> EHD LOG#: O �� <br /> A. EMERGENCY LEVEL: I 11 III <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: <br /> r n �j— Z�G Phone: ( ) <br /> Company: Zip Code: <br /> Address: I �� � �nfr.n City: <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: <br /> City: Zip Code: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> /`7 S � / -(E County <br /> Location: lOne) <br /> (Best Physical Descnption) <br /> A.M. <br /> Date of Discharge: 1t b Date Notified: <br /> Time: <br /> D. RESPONSIBLE PERSONBUSINESS <br /> Name of Business: Phone: ( ) <br /> Contact Person: Zi Code: <br /> Physical Address: `F . City: p <br /> Mailing Address: l 9�f <br /> City: Zip Code: <br /> E. DESCRIPTION - <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: _A ` �--" t9 ° v <br /> --lo <br /> F. ACTION ACTION TAKEN: <br /> ---------------------- <br /> W <br /> SITE DISPOSITION: <br /> z <br /> Notification or Haz Discharge <br /> EHD 22-02-003 <br />