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SAN JOAQUIN COUNTY <br />D <br />M�� D <br />ENVIRONMENTAL HEALTH DEPARTMENT qT <br />600 East Main Street Stockton • CA 95202-3029 <br />• (209) 468-3420 - Fax.- (209) 464-0138 - Web: www.sigov org/ehd <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />A. EMERGENCY LEVEL I II III EHD LOG# <br />" I <br />B. SOURCE OF INFORMATION <br />LADDRESS: <br />L. JVt.,A j IUIN Amu UA I h ur VIZ&H"uh <br />LOCATION: v CITY 1,4Imorporated <br />Best Physical Description I LZ Unincornorated <br />DATE OF DISCHARGE: —7— <br />DATE NOTIFIED: TIME: <br />L%X, vaiaa Fr-,AakALNIDVall-4a <br />NAME OF BUSINESS: <br />CONTACT PERSON: <br />PHONE: <br />5-7 <br />PHYSICAL ADDRESS: tttk;;1f4V1 -m.0 f4xjzj,1tqCt) 13-7Lj <br />MAILING ADDRESS- <br />CIRCUMSTANCES: <br />DESIGNATE <br />LADDRESS: <br />L. JVt.,A j IUIN Amu UA I h ur VIZ&H"uh <br />LOCATION: v CITY 1,4Imorporated <br />Best Physical Description I LZ Unincornorated <br />DATE OF DISCHARGE: —7— <br />DATE NOTIFIED: TIME: <br />L%X, vaiaa Fr-,AakALNIDVall-4a <br />NAME OF BUSINESS: <br />CONTACT PERSON: <br />PHONE: <br />5-7 <br />PHYSICAL ADDRESS: tttk;;1f4V1 -m.0 f4xjzj,1tqCt) 13-7Lj <br />MAILING ADDRESS- <br />I�DIWTOW%W-fff- in <br />TYPE OF DISCHARGE: <br />VOLUME: <br />CHEMICALS: <br />CIRCUMSTANCES: <br />F. ACTION TAKEN -f <br />V1 YTV"- <br />A&Y-r <br />M� MIX <br />ER RECORD MODIFIED <br />Revised 05/01/2007 <br />