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f` 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.sFgov.org/ehd <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> A. EMERGENCY LEVEL 91 ❑ II ❑ nl JEHDLOG# I I 3 <br /> B. SOURCE OF INFORMATION p <br /> NAME: LCs✓or PJ 'lr1 PHONE: <br /> �'arp0l 77�' Z <br /> COMPANY: kT t-A -yC1C //'' I CITY: Z4 >h"/ti <br /> ADDRESS: 3135 A4,,-f4-f4r4;,-fe)d IeDD O//:, gle J <br /> DESIGNATED EMPLOYEE NAME: /Vvel wP-Son PHONE: 999 <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: 270 W e572k S'-I«e t nwr orated <br /> Best Physical CIN <br /> Description ❑ Unincorporated <br /> DATE OF DISCHARGE: urtv'eW'1 <br /> DATE NOTIFIED: K'N-C4L ZLJ 2o4 TIME: y'u pw <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> NAME OF BUSINESS: Wem-tw G Pyb rie 5 <br /> CONTACT PERSON: `n C PHONE: <br /> (IL ege <br /> PHYSICAL ADDRESS: 2 W, &k ,5flee-FAL A?cc, l/ p9 33 7 <br /> Z <br /> MAILINGADDRESS: S !d, O ,t 54-eC-f. �/eea t / <br /> � 5/' <br /> E. DESCRIPTION <br /> TYPE OFDISCHARGE: Un u,:1 <br /> VOLUME: V.LI„' w'1 <br /> CHEMICALS: G'-k/oroyrlrH <br /> A, 711114rJZ7GG Jin Or(o 9rYLfi r7 to ke.�ev 5 f!e <br /> CIRCUMSTANCES: (/ <br /> F. ACTION TAKEN <br /> bulli/e 7�,77 65 <br /> SITE DISPOSITION <br /> Revised 08/02/12 Page 1 of 2 NOTIFICATION OF HAZ WASTE DISCHARGE <br />