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6" <br />L <br />SAN JOAQUIN COUNTY -II <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street Stockton -, CA 95202-3029 <br />(209) 468-3420 - Fax. (209) 464-0138 - Web: www.sjgov.org/ehd <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />A. EMERGENCY LEVEL X 1' EHD LOG7#7]-7 <br />0,9 <br />T <br />NAME: <br />C')-1 C fz-f- <br />C <br />PHONE: <br />PHONE - <br />COMPANY: <br />PHYSICAL ADDRESS: <br />(j I,1.5 oy, <br />CITY: <br />CIRCUMSTANCES: <br />CctLA <br />ADDRESS: n1p C5 <br />DESIGNATED EMPLOYEE NAME: <br />PHONE: <br />REPORTING AGENCY NAME; <br />04,,V4� <br />ADDRESS- <br />k4r�k <br />r.A <br />C. LOCATION AND DATE OF DISCHARGE <br />LOCATION: CITY Incorporated <br />Best Physical Description <br />e-- Unincorporated <br />DATE OF DISCHARGE: 1 <br />DATE NOTIFIED:C? 12-1,,-2 <br />TIME: <br />D. RESPONSIBLE PERSON/BUSINESS <br />NAME OF BUSINESS: <br />CONTACT PERSON:vi <br />0 <br />PHONE - <br />PHYSICAL ADDRESS: <br />(j I,1.5 oy, <br />MAILING ADDRESS: <br />CIRCUMSTANCES: <br />E. DESCRIPTION <br />TYPE OF DISCHARGE: <br />VOLUME: <br />CHEMICALS: <br />CIRCUMSTANCES: <br />I,. AL.� L WIN I AKhN <br />C' <br />-4e 1�C "S <br />44 Vj IS AdOA— FA 0 <br />M,qbz/-", <br />ER RECORD MODIFIED Revised 0510IJ2007 <br />