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Pg'"" SAN JOAQUIN COUNTY d <br /> �T a ENVIRONMENTAL HEALTH DEPARTMENT Z6y a <br /> 600 East Main Street Stockton - CA 95202-3029 <br /> (209)468-3420•Fax:{209)464-Oi38• Web:www.s' ov.or eh ff <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL I-XI I I EHD LOG# I I q,3 <br /> B. SOURCE OF INFORMATION <br /> NAME: PHONE: <br /> COMPANY: �� Q J'� CITY: <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: / /� CITY Incorporated <br /> Best Physical Description Al, <br /> /, /I /I /J I/7 1 -, <br /> f�� �V 1 C'�..r�/(„J Unincorporated <br /> DATE OF DISCHARGE: 17/1:2- // <br /> DATE NOTIFIED: V —n-a d TIME: •��5 /'j'1 <br /> D. RESPONSfBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: <br /> CONTACT PERSON: PHONE: <br /> PHYSICAL ADDRESS: <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: %L L <br /> l <br /> VOLUME: <br /> CHEMICALS: ct e-, y <br /> CIRCUMSTANCES: <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> i7,� W Azer 4-,e� 6Zea, ,6'W 4Z <br /> ER RECORD MODIFIED Revised 05/01/2007 <br />