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�oaq :±l <br /> ..co SAN JOAQUIN COUNTY Q <br /> , <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton■CA 95202-3029 <br /> .:; `•` (209)468-3420■Fax:(209)464-0138 • Web:www.sjgov.orglehd <br /> Q�f OR `P l _ . <br /> NOTIFICATION..OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL . IXI I1 1iiI EHD LOG# <br /> B. SOURCE OF INFORMATION <br /> NAME: T&41=q PHONE: <br /> COMPANY: n� CITY: C'�r <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: - <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: �d 1 CITY ��� Inco orated <br /> Best Physical Description <br /> .1 FrUnincorporated <br /> DATE OF DISCHARGE: I O <br /> {DATE NOTIFIED: 417 TIME: <br /> -D. RESPONSIBLE PERSON/BUSINESS <br /> *NAME OF BUSINESS: �! <br /> CONTACT PERSON: S PHONE: <br /> PHYSICAL ADDRESS: <br /> y <br /> i <br /> MAILING ADDRESS: �. <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: <br /> CHEMICALS: 14L j <br /> q <br /> CIRCUMSTANCES: <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> ER RECORD MODIFIED Revised 05/0112007 <br />