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SAN JOAQUIN COUNTY •.� � �1 s <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: TPrr�z Vnghi nkn Phone: UD-9) 468-3420 <br /> Company: Sa Joaquin County Environmental Health Serizi mac <br /> Address: <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: Env; onm t,n t-a 1 NPa 1 th <br /> Address: 445 N. San Joao-din Stockton <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 4315 E . Waterloo Road Stockton. CA 9520/5 <br /> (Best Physical Description) (Ci or County) Circle One <br /> Date of Discharge: Unknn-m <br /> Date Notified:12/07/94 Time: 2 . 00 pm <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: Shell Service Station (Shell Oil Company) <br /> Contact Person: Jeff Granberry Telephone: 10 675-6145 <br /> Physical Address: 1 -390 Wi 1 1 nT7 Pass Pond ,_$111 to 900 ,--rer}Gerd,CA 94524 <br /> Mailing Address: same <br /> E. DESCRIPTION <br /> Type of Discharge: Fuel release from underground mage tank CtTCzt-Pm <br /> Volume: Unknown <br /> Chemicals: Gasoline <br /> Circumstances: Unknown, release discovered during system removal . <br /> F. ACTION TAKEN_ System removed and tank excavation sampled. <br /> SITE STATUS UST contamination Gri 11 he cinr„mantPrl wi th TTAR ^ a <br /> to contaminated site database . Further investi _ation and rem d t ay <br /> e required by EH and/or CVRWOCB <br /> EH 22 013 (Rev-4/91) <br />