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p c° SAN JOAQUIN COUNTY <br /> � ENV�PWJNMENTAL HEALTH DEPARTMl.., F�L' C 0 p <br /> 600 E. Main Street, Stockton, CA 95202 <br /> (209)468-3420•Fax:(209)464-8392• Web:www-CO-san-joaquin.ca.us/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> �S California Health & Safety Code, Section 25180.7 <br /> EHD LOG#: <br /> EMERGENCY LEVEL: rr rrr <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: QA <br /> l Phone: (zo-L) <br /> Company: r <br /> Address: �-q -'r a�i City: __Sk o - -1•-nt.. `Zip Code: s^ <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: City: Zip Code: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: J D F- ,,A- / Cit or Count <br /> (Best Physical Description) (Circle One) <br /> Date of Discharge: wwv,, Date Notified: v'1- Time: A.M. P.M. <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: �.,,.�,� [ Phone: ( ) <br /> Physical Address: o City: Zip Code: �� Z <br /> Mailing Address: _41. 3� r„f'r&n.c.wflo� c.E- City: ,,, Zip Code: m t -� <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: r[����-�� —�_o e ( ���p�.k.�c.� �-- •,{���...Gl-s ,lore <br /> F. ACTION TAKEN: <br /> SITE DISPOSITION: t=10 45L` <br /> Nll <br /> v �t <br /> EHD 22-02-003 <br /> 05/04/07 Notificatiott of Haa Discharge <br />