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PqU'I SAN JOAQUIN COUNTY0�1- <br /> O P <br /> z ENVIRONMENTAL HEALTH DEPARTMENT <br /> ..� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> P (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# 1 14-0-7 <br /> B. SOURCE OF INFORMATION pR <br /> NAME: AK ��WfPHONE: r U <br /> COMPANY: 2, CITY: <br /> ADDRESS: \4 Ao�s <br /> DESIGNATED EMPLOYEE NAM Aris 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: �` <br /> ❑ Incorporated <br /> Best Physical CITY <br /> Description / Unincorporated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: TIME: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: <br /> CONTACT PERSON: PHONE: - KIld?- <br /> PHYSICAL ADDRESS: vl�l <br /> MAILING ADDRESS: ( q 22L <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: <br /> CHEMICALS: mt4W <br /> CIRCUMSTANCES: <br /> F. ACTION TAKEN <br /> W'g' �am� <br /> SITE DISPOSITION <br /> 6*'� 1 '�t� M I <br /> Revised 04/19/12 Page 1 of 2 NOTIFICATION OF HAZ WASTE DISCHARGE <br />