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SAN JOAQUIN COUNTY <br />�y ENVIRONMENTAL HEALTH DEPARTMENT FILE COPY <br />N •t <br />304 East Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />c P (209) 468-3420 • Fax: (209) 464-0138 • Web: vrdvw.co.san-joaquin.ca.us/ehd <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />California Health & Safety Code, Section 25180.7 <br />EHD LOG #: O 5. 0 a'� <br />A. <br />C. <br />Q <br />E. <br />F. <br />EMERGENCY LEVEL II III <br />(Circle One) <br />SOURCE OF INFORMATION <br />Name: i�� W006 Phone: Goal) 334f -0017s <br />Company: �(A5 G0-7 G eU <br />Address: (o1*42J C*P'o b L gye. City: LOO i Zip Code: gSZK'L <br />VA4 P <br />Designated Employee Name: <br />Reporting Agency Name: <br />Address: <br />City: Zip Code: <br />LOCATION AND DATE OF DISCHARGE <br />Location: b L4'1. ( CAP 1 1✓d L 4u?, <br />(Best Physical Description) <br />(Ci <br />Date of Discharge: 15 lid a Date Notified: S Time: 'q OZ) A. P.M. <br />RESPONSIBLE PERSON/BUSINESS <br />Name of Business: <br />Contact Person: <br />Physical Address: <br />Mailing Address: <br />DESCRIPTION <br />Type of Discharge: <br />Volume: <br />Chemicals: <br />Circumstances: <br />LCAK-t/ DLA 1^5 Fj Phone: <br />t,2 c,t21 Cerpl ol, 4Le—, City: COPi Zip Code: 117sZ-,44'1- <br />I( u <br />City: <br />Zip Code: le <br />ACTION TAKEN: <br />11 <br />PUI <br />SITE DISPOSITION: C f ►h �^4� w in d ryrv-s "9A. S 1 %. <br />cvn 11_M..M7 <br />Notification of Haz Discharge <br />