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`'' •c 0 SAN JOAQUIN COUNTY <br /> z �?, ENVIRONMENTAL HEALTH DEPARTMENT F � <br /> D <br /> ` 600 East Main Street Stockton■CA 95202-3029 <br /> (209)4683420.Fax.(209)464-0138■ Web:www.sjgay.org[ehd <br /> NOTIFICATION OF HAZAI&DOUS WASTE DISCHA <br /> Ah <br /> A.• EMERGENCY LEVEL EHD LOG# <br /> B. SbURCE OF'INFORMATION <br /> NAME: ex "4' epJ, PHONE: SS+(/ <br /> - <br /> A34 Cgtwy <br /> COMPANY: t CrrY: <br /> ADDRESS: II 0% u>r � 6ke� CA '?S5 <br /> 1 <br /> DESIGNATED EMPLOYEE N . PRONE: 33�- �j9a2 <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: e$U Mrj�R vAP�/ : Ti/�C�/1 (A q�j ` CITY ✓�f�� / rated <br /> Bat Phys9oal Deaa#don / / i <br /> / Unincorporated <br /> DATE OP DISCHARGE: <br /> DATE NOTIFIED: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: <br /> CONTACT PERSON: e( PHONE: <br /> PHYSICAL ADDRESS: 11ft lr w ,(kQ. dS 64 -1,S341 <br /> MAILING ADDRESS: It Is I/Y 1 e A44 (A 9 <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: { 4AJ 11111 0 Ad VOW, nuww JVV4&-Ww-. <br /> VOLUME: L <br /> CHEMICALS: i <br /> CIRCUMSTANCES: MIAWO Q i f a <br /> F. ACTION TAKEN <br /> l ex e1 e �uv e� �v a ?6 crew s f)PI&w,. 4e c1&Aj <br /> (S�rrE DISPOSITION <br /> !!v . <br /> ER RECORD MODIFIED Revised 05/01/2007 <br />