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SAN JOAQUIN OUNTY '1 <br /> ENVIRONMENTAL HEAL:-H.DEPARTMENT <br /> y _ 304 East Weber Avenue, Y Floor, tocktori,CA 95202-2708 <br /> 209)468-3420■Fax:(209)464-0138 • Web:w�bw.co.san-joaquin.ca.us/ehd <br /> IF CATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code 5ect'on 180.7 I <br /> _._ -.-EHD LOG#:... ,.Q <br /> 21 <br /> A. EMERGENCY LEVEL:f I/ II III <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: �n.-- I3l�rn-ti.e.�-e Phone: <br /> Company: {� ,wc�uo� .,�-�'�a� i ta•,—f <br /> Address: tt . Z-©0 City:&" e1ci� - Onip Code:510 0 <br /> Designated Employee Name: 14-46-6#J K�Jo <br /> Reporting Agency Name: 5A il) C <br /> Address: dL City:STID Zip Code: 7f <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 8 L'`'`am1 Ci or Count <br /> (Best Physical.Descriptio (Circle One) <br /> Date of Discharge: . [,^,� Date Notified Timer:°,) "'u P.M. <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business- Aq& # <br /> Contact Person: Phone: ( ) <br /> Physical Address: ' i✓ �►^a-- City: eP� Zip Code:�/'fo <br /> .� <br /> Mailing Address: Z-OD City: Zip Code: <br /> E. DESCRIPTION <br /> Type of Discharge: uy_^J4ffU4%,/ <br /> Volume: tt,_,k-^^-6 <br /> Chemicals: G sc&,� <br /> Circumstances: ,A a,_ <br /> F. ACTION TAKE <br /> N: 3 rev A,r� A4,*f <br /> �Jt.C� v cry S <br /> 1 <br /> SITE DISPOSITION: At a t� � �� t G .0 ., <br /> _ A <br /> 01 <br /> Notification of Haz Discharge <br /> EHD 22-02 3 "° r <br /> rnMMMR - ....,, A t4 <br />