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SAN JoAQunv COUNTY <br /> ` <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> i '304 East Weber Avenue,P Floor, Stockton, CA 95202-2708 <br /> (209)468-3420.Fax:(209}464-0138 • Web:*ww.c0.san-joaqum.ca.us/ehd <br /> .co.san-joaquin.ca.us/ehd` <br /> FO P <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 25180.7 <br /> _. .EHD LOG#: 6 4 0 I <br /> A. EMERGENCY LEVEL: I II <br /> (C e One) <br /> B. SOURCE OF INFORMATION phone: (Zog) <br /> Name: J f <br /> off eeL <br /> Company: .S City: �G Zip Code: <br /> Address: <br /> Designated Employee Name: <br /> Reporting Agency Name: Zip Code: <br /> Address: City: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location �53� `�' ����'` ' �� 1 CiN <br /> HIOne)t <br /> (Best Physical Description) Sf <br /> Date of Discharge: Date Notified: <br /> Az' /L61 y Time: <br /> D. RESPONSIBLE PERSON/BUSINESS e (2ag) (163 - <br /> Name of Business: 3 ^ 8 / <br /> � one: z@'1) <br /> Contact Person: oc av Zi Code: <br /> Physical Address: 30 N 4 f�dd City: <br /> Mailing Address: f p �,sZO Z <br /> !l� G �a City: - S Zip Code: <br /> - <br /> E. DESCRIPTION <br /> t <br /> Type of Discharge: rn , <br /> Volume: L <br /> Chemicals: <br /> Circumstances: 111176 <br /> F. ACTION TAKEN: yn <br /> . A <br /> PIC <br /> SITIE DISPOSITION: . <br /> L o <br /> Notification of Haz Discharge <br /> EHD 22-02-003 <br />