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off`.... ' •c SAN JOAQUIN COUNTY <br /> �:_��••,off <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> { 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c.• .__- <br /> -^ (209)468-3420 - Fax:(209)464-3433■ Web:www.sigov.orq/ehd <br /> ��i F o•5z�• <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL 01 ❑ 11 ❑ 111 EHD LOG# IfC)t J <br /> B. SOURCE OF INFORMATION f <br /> NAME: b Vl/1 UU�1 PHONE: ��� LH 4- M <br /> COMPANY: u I/ CITY: (,V' <br /> ADDRESS: a ( h i <br /> vv <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: A-Q" �tY'KLt/w Incorporated <br /> Best Physical �j+ !I� -�' lr-7 t �G4�. n ! CITY �g�. p <br /> Descri tion j-'��I �) U h 1`�(Q ILGI Unincorporated <br /> � .J <br /> DATE OF DISCHARGE: (' ' 3 <br /> DATE NOTIFIED: TIME: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: P w l\- !--\j� P/r 1 <br /> CONTACT PERSON: PHONE: <br /> PHYSICAL ADDRESS: us (ff r' I OL) ( MAI Pa —fi , v <br /> MAILING ADDRESS: p 6 ��I;y( , <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE <br /> VOLUME: U �� <br /> CHEMICALS: <br /> -�i�•2R "LI-CL�t fi� c� 'vu <br /> CIRCUMSTANCES: <br /> F. ACTION TAKEN <br /> PCUA Af\Ql <br /> &AU'VIft, 6�ytk Ur W1 <br /> v SITE DISPOSITION � wil � ✓ ✓ V ,� v <br /> Revised 08/02/12 Page 1 of 2 NOTIFICATION OF HAZ WASTE DISCHARGE <br />