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o?'PLViN c SAN JOAQUIN COUNTY (J <br /> N y{ ENVIRONMENTAL HEALTH DEPARTMENT (� <br /> 600 East Main Street Stockton • CA 95202-3029 O <br /> �'• (209)468-3420 • Fax:(209)464-0138 • Web:www.sjizov.ora/ehd <br /> RSI FOR% <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL 1X11 I I 'llFfF1 EHD LOG# <br /> B. SOURCE OF INFORMATION <br /> NAME: 7c�� ��'ljl� PHONE: <br /> COMPANY: CITY: <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: Muniappa Naidu PHONE: (209)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: 4 (A fZ,,,y �2�„�(� G,4wg,) CITY � �' X incorporated <br /> Best Physical Description <br /> Unincorporated <br /> DATE OF DISCHARGE: cil 1 <br /> DATE NOTIFIED: TIME: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: bi 19 ,S (`—y ell <br /> CONTACT PERSON: �e,�.y� ✓C v/$)��2 _ �'IF�� PHONE: 2,0q — 05 f'�y <br /> PHYSICAL ADDRESS: <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: / l�w�, �� ��,ti1,(/� (� /Y1G✓K '� <br /> VOLUME: 3zoo <br /> CHEMICALS: <br /> CIRCUMSTANCES: 0 C4�0-61/I1.1/ <br /> F. ACTION TAKEN <br /> y <br /> SITE DISPOSITION <br /> CLc ,. (A/ <br /> ER RECORD MODIFIED Revised 05/01/2007 <br />