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° DSAN JOAQUIN COUNTY <br /> r. <br /> 'F a ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton F CA 95202-3029 <br /> (209)468-3420•Fax:(209)464-0138 • Web:www.sigov.org/ehd <br /> L+�oR <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> 1 <br /> A. EMERGENCY LEVEL FX I I I I rl EH D LOG# 0 - Q <br /> B. SOURCE OF INFORMATION // <br /> NAME: w 1 �sLa� r PHONE: (a�r p 2COMPANY: ! CITY: <br /> ADDRESS: g7c;, lJ. o W 4v— <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: -� <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: Z�pp v �++>�'"`!5 CITY ±t�?unincorporated <br /> co rated <br /> Best Physical Desc*iots <br /> DATE OF DISCHARGE: aV <br /> DATE NOTIFIED: TIME: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: frre-y�.jy,o, <br /> CONTACT PERSON: PHONE: <br /> PHYSICAL ADDRESS: ea�it> hS ' �� <br /> MAILING ADDRESS: X14 <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: -532i I <br /> VOLUME: <br /> CHEMICALS: <br /> CIRCUMSTANCES: <br /> F. ACTION TAKEN <br /> to— <br /> SITE DISPOSITION <br /> wilt 6x S�--f W 14 <br /> ER RECORD MODIFIED Revised 05/0112007 <br />