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Ac- <br /> e"" SAN JOAQUIN COUNTY COO u <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209)468-3420• Fax: (209)464-3433 • Web:www.sigov.org/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL ❑x 1 ❑ II ❑ III EHD LOG# <br /> B. SOURCE OF/I INFORMATION <br /> NAME: C k; fen- PHONE: "N79- <br /> COMPANY: CITY: <br /> ADDRESS: <br /> DESIGNATED EMPL YEE NAME: Alis Cacapit PHONE: (209)468-3453 <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: `� �,,.,J,(, bN F__. <br /> N1 OeIN1V� YGV '�- Inco orated <br /> Best Physical CITY <br /> Description Unincorporated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: —(x-12 TIME: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: <br /> CONTACT PERSON: em PHONE: I QM) 3 - // Z <br /> PHYSICAL ADDRESS: Ila cA 22 '90j6 <br /> MAILING ADDRESS: <br /> E. DESCRIPTIO�N(��t��t <br /> TYPE OF DISCHARGE: w <br /> VOLUME: <br /> CHEMICALS: 0 1=L ►,I._ q7 ,�+,, <br /> Gw <br /> CIRCUMSTANCES: <br /> r-,Q�_. , ArA it 1 <br /> F. ACTIONTAKEN <br /> <-�V* ul," <br /> SITE DISPOSITION <br /> S .G . 00 t lei/ AT �12✓ C�m up I <br /> Revised 04/19/12 / 1 Page 1 of 2 NOTIFICATION OF HAZ WASTE DISCHARGE <br />