Laserfiche WebLink
SAN JOAQUIN COUNTY D <br /> 4. <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> .,. <br /> 600 East Main Street Stockton • CA 95202-3029 <br /> (209)468-3420•Fax:(209)464-0138• Web:www.sjgov.org(ehd <br /> i�0 r <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHA <br /> A. EMERGENCY LEVEL I x I LKHD LOG# 1 10— ' <br /> B. SOURCE OF INFORMATION -- <br /> NAME: r Q�6/ PHONE: <br /> COMPANY: — - CITY: <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: "Y7 X71 Zd 2 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: n� CITY Inco rated <br /> Best Physical Description Q CJ <br /> Unincorporated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: 2Ll 0 TIME: �D <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: <br /> CONTACT PERSON: PHONE: 01 —�JJ� <br /> PHYSICAL ADDRESS: <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: <br /> CHEMICALS: �JQcs <br /> CIRCUMSTANCES: <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> ►(��� i`r�omp <br /> ER RECORD MODIFIED Revised 05/01/2007 <br />