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OAca U I iy c� SAN JOAQUIN COUNTY D <br /> Q`. . ?• ENVIRONMENTAL HEALTH DEPARTMENT <br /> ?: 600 East Main Street Stockton • CA 95202-3029 <br /> 209 468-3420•Fax: 209 464-0138 • Web:www.sjpov.org/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL I x I II III EHD LOG# ,Q 3 <br /> B. SOURCE OF INFORMATION <br /> D' <br /> NAME: tv M <br /> 15•/ 4A1 PHONE: 14G7-/e O <br /> CITY:c�U « &0,, ll5t0 � <br /> k0e , <br /> ADDRESS: S klLt-� R <br /> DESIGNATED EMPLOYEE NAME: PHONE: <br /> REPORTING AGENCY NAME: <br /> ADDRESS: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: Z 33.E E � CITY Q i p�L y� V Incorporated <br /> Best Physical Description <br /> Unincorporated <br /> DATE OF DISCHARGE: <br /> DATE NOTIFIED: TIME: Atowv,-, <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: -LW\ - C47,1f <br /> / <br /> CONTACT PERSON: L . sem. -S PHONE: <br /> PHYSICAL ADDRESS: CA '?S3- 3 & <br /> MAILING ADDRESS: <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: am <br /> VOLUME: k10 IUIK/ <br /> CHEMICALS: <br /> CIRCUMSTANCES: <br /> F. ACTION TAKEN <br /> pl,,, Z- X jjo . <br /> SITE DISPOSITION <br /> .5r�pw+-� o��c.o>►�.� -u+?�Oa- ..cam.dt���C- � d,ad.�ee�,�� <br /> FR RI CORD MODIFIED Revised 05/01/2007 <br />