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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304.East Weber Avenue,k'Floor,Stockton, CA 95202-2708 . COPY <br /> (209)468-3420-Fax.(2.09)464-0138• Web.v ww.co.san-joaquin.ca.us/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code,Section 25180.7 <br /> EHD LOG#:6� OSS <br /> A. EMERGENCY LEVEL: II III <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: 1 Phone: (J$%) <br /> Company: <br /> Address: City: Zip Code: <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> i. Address: City: Zip Code: <br /> 4 .h <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: loo 64 0.40 I*R t, YoV , CK / City or eounty <br /> (Best Physical Descrip 'on) (Circle ne <br /> t51,4110:1 <br /> Date of Discharger o Date Notified: Time: l <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: nv) <br /> i Contact Person: -E. TJi G Phone: (gjjj) If l 5{5 f <br /> ! q � <br /> Physical Address: Q�St_IiVbiD R 4t,- 101 City: 91seyilk Zip Code:�'nj <br /> Mailing Address: City: Zip Code. <br /> E. DESCRIPTION <br /> Type of Discharge: 'SpAti <br /> 1 Volurhe: S <br /> Chemicals: Y il <br /> 'i <br /> Circumstances: u�t u r <br /> F. ACTION TAKEN: vvt :U aYi <br /> vi . vi a4le <br /> SITE DISPOSITION: <br /> EHD 22-02-003 Notification of Haz Discharge <br /> 10/2/2003 <br /> r `_ <br />