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SAN JOAQUIN COUNTY �U <br /> { ENVIRONMENTAL HEALTH DEPARTMENT d <br /> 600 E.Main Street, Stockton, CA 95202-3029 r -08 <br /> Telephone:(209)468-3420 Fa (209)468-3433 Web:www.sjgov.org/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHAR(a*11M <br /> California Health & Safety Code,Section 25180.7 <br /> EHD LOG#: OS 0 1? 3 <br /> A. EMERGENCY LEVEL II III <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> �t� <br /> Name: 0 � /I <br /> t�, t� Phone: e.-7.1) <br /> Company: . 6- --F r <br /> Address: Q. D . tZ City: Zip Code: 6C <br /> 2 <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: City: Zip Code: <br /> C. LOCATION AND DATE OF DISCHARGE 6A <br /> Location: 2 LIC) i r D /2 �QA� 0'19'% / cit o coup <br /> (Best Physical Description) r� (Cirri <br /> Date of Discharge: t $ Date Notified: �� Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: P, &• 'C F <br /> Contact Person: M f a-,,P t t<, b?— - Phone: 90-1 <br /> Physical Address: City: Zip Code: <br /> Mailing Address: i�L�—��k City U u L Zig Code: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: h i /7?,-j D '✓1 T/�M S b <br /> Circumstances: `f"/`4 �aMns� ___� •l l L <br /> F. ACTION TAKEN: C <br /> SITE DISPOSITION: 1 <br /> EHD 22-03 Notification of Haz Discharge <br />