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i <br /> oP:. 'N••.c SAN JOAQUIN COUNTY � jR/7 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)466-3420• Fax:(209)464-3433• Web:www.siaov.ora/ehd <br /> \tel F ORN <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL ❑x I ❑ II ❑ III JEHDLOG# I / -D/Q <br /> B. SOURCE OF INFORMATION (^ <br /> NAME: PHONE: W <br /> COMPANY: CITY: cd 44 <br /> ADDRESS: b <br /> DESIGNATED EMPLOYEE NAME: PHONE: <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: bl hsn.W.'i- I (, /,y;I„ incorporated <br /> Best Physical 1 �tt ae "t CITY <br /> Description � �'t'll� L1- Unincorporated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: '/" O - r TIME: (Qj <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: <br /> CONTACT PERSON: PHONE: d- <br /> PHYSICAL ADDRESS: aa t r ca <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: Gt•C�l, L <br /> VOLUME: o olk <br /> CHEMICALS: t✓ t <br /> CIRCUMSTANCES: ,�`L!„ <br /> F. ACTION TAKEN s ld lLS WAC 1� <br /> SITE DISPOSITION <br /> (L`�tn7� vv* EXU VA iot <br /> Revised 08/02/12 Page 1 of 2 NOTIFICATION OF HAZ WASTE DISCHARGE <br />