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qt�4. SAN JOAQUIN COUNTY <br /> =` ENVIRONMENTAL HEALTH DEPARTMENT � (0 rt \/7 <br /> ` <br /> 600 East Main Street Stockton • CA 95202-3029} <br /> +� P (209)468-3420•Fax:(209)464-0138• Web:www.sJgov.orggr/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL I x II u IrI EHD <br /> B. SOURCE OF INFORMATION <br /> NAME: LJ pc� �Lt PHONE: —7Z6-7 <br /> COMPANY: CITY: <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: Muniappa Naidu PHONE: 9)468-3439 <br /> REPORTING AGENCY NAME: Environmental Health Department <br /> ADDRESS: 600 E Main Street,Stockton,CA 95202 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: iJ{ ,` (yn CA CITY 1 Q )��(f� Incorporated <br /> Best Physical Description I D�� '�-�-%� ^ l•`Ay� 7EX <br /> Uninco orated <br /> DATE OF DISCHARGE: Z( 1 p f q- <br /> DATE NOTIFIED: "2 1 0 ! TIME: 2 3,e3 Q,l .,, <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: - f�`, <br /> CONTACT PERSON: V� NS <br /> PHONE: ��� � � <br /> PHYSICAL ADDRESS: �, I (� G jp y I �Z -7--2Z/'s' <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: 1�/� � <br /> VOLUME: <br /> CHEMICALS: ( /V P►�lY>�— <br /> CIRCUMSTANCES: "P� �-� F L rN S'L�ec� Un,•tk �,,.;�( c�F. ACTION TAKEN <br /> SITE DISPOSITION <br /> ER RECORD MODIFIED Revised 05/01/2007 <br />