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o?`'":.'N..c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street Stockton•CA 95202-3029 <br /> k ` (209)468-3420•Fax:(209)464-0138 • Web:www.sigov.org/ehd <br /> ���FORa <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL 1X1 ' I I 'lllu EHD LOG# <br /> B. SOURCE OF INFORMATION <br /> NAME: PHONE: <br /> COMPANY: CITY: <br /> ADDRESS: <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: •„// CITY Inco orated <br /> Best Physical Description n(fJ1 /I/Tfl(� ( �'(�J/ <br /> Unincorporated <br /> DATE OF DISCHARGE: (S p <br /> DATE NOTIFIED: 11 s TIME: ,do Dhn <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: l ew— ih( >) 1 r, it 1i1� <br /> CONTACT PERSON: PHONE: �a <br /> PHYSICAL ADDRESS: S. 6tct 5 3 <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: I� <br /> VOLUME: <br /> CHEMICALS: a a <br /> CIRCUMSTANCES: v.� (J� <br /> F. ACTION TAKEN <br /> SP M Vt&-,k 0,-, <br /> Dom bkV <br /> SITE DISPO1SSIITION <br /> qc, <br /> ER RECORD MODIFIED Revised 05/01/2007 <br />