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ri <br /> ,o? y.coc SAN.TOAQUIN COUNTS <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> • Y�� !` 600 East Main Street Stockton•CA 95202-3029 <br /> (209)468-3420•Fax. (209)464-0138• Web:www.sicov.orPJeHd <br /> t/FOIL )[1r <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL I x EHD LOG# I) -I) y <br /> B. SOURCE OF INFORMATION <br /> NAME: ��� rS> o.--.. PHONE: <br /> COMPANY: G•,r CITY: o <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCION: ZGj % 77 CITY Z L4.f h Inco ted <br /> AT <br /> Beat PLAT nesrigou <br /> Unincorporated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: —I - C� TIME: 3 U <br /> D. RESPONSMLE PERSON/BUSWM <br /> NAME OF BUSINESS: <br /> CONTACT PERSON: oc �rf 5 so... PHONE: <br /> PHYSICAL ADDRESS: s5l <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: <br /> VOLUME: h-4XiwM�.— o (700 jb5, <br /> CHEMICALS: <br /> CIRCUMSTANCES: <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> 61--k—� ��Qoirq. <br /> ER RECORD MODIFIED RrAwd 05/012007 <br />