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. � r <br /> N� <br /> LJ <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> (209) 468-3420 • Fax:(209)464-3433• Web:www.sigov.org/ehd <br /> S�/FOF� <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL 01 ❑ II ❑ III EHD LOG# - 6 Cq-Z- <br /> B. <br /> B. SOURCE OF INFORMATION <br /> NAME: 6c-v Uvhrl <br /> COMPANY: gr,.j-M'7-. h -r/"L,. CITY: L -fort , tHz�i. 87w�[! <br /> ADDRESS: 31.3.5) 9p.* FiC -'r Yre.ld Rds.• . 10 <br /> DESIGNATED EMPLOYEE NAME: Np I H ehd efs0✓N I PHONE: <br /> REPORTING AGENCY NAME: San Joaquin County Environmental Health Department <br /> ADDRESS: 1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LOCATION: •Zrj I Oak 5-!'rce.-1" ncor orated <br /> Best Physical CITY Ment, r{tc'� <br /> Description ❑ Unincorporated <br /> DATE OF DISCHARGE: Uh kid rvvl <br /> DATE NOTIFIED: /l7Ltli-/i. 2 ri Zv TIME: yf ZG <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: lner <br /> CONTACT PERSON: '1" eit. f*z PHONE: <br /> PHYSICAL ADDRESS: 25 W. ©wk 6��reB/ e[k C -9-x33 7 <br /> MAILINGADDRESS: 05-1 40, 0c1SrLef— 4,t, f{ 33;7 <br /> E. DESCRIPTION <br /> TYPE OF DISCHARGE: V <br /> VOLUME: !fin It V1 La V) r__�._ '1 <br /> CHEMICALS: P'*re leujle � dre)f"&-4M f r-15 53 IPHJ) r <br /> 0,1e iwfertnecFafe deo*eL �'rr6It-r444-�er3z{ty0l1� cdh&4,, the 'TI°Fld <br /> CIRCUMSTANCES: Qf 2701,1(L _6,,,f dit)/Jaj- mof'ch toe d reJt/S .,Jtr%? ,4r1Ot4er• uiu-'Eer <br /> F. ACTION TAKEN <br /> e"wptetc +�c fry lob11offIz4�r <br /> SITE DISPOSITION <br /> r <br /> rY�i:ae pian P/lr.1NCG� po re rre'-44* anf Aev 4,JP Ky <br /> Revised 04/19/12 Page 1 of 2 NOTIFICATION OF HAZ WASTE DISCHARGE <br />