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a� �+ SAN JOAQUIN COUNTY FILE <br /> � <br /> s ti ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,P Floor, Stockton, CA 95202-2708 <br /> (209)468-3420•Fax:(209)464-0138• Web:ww vxo.sanjoaquinxa.us/ehd <br /> dQC RORa`P <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 25180.7 <br /> EHD LOG#: C 4 — Q Lb <br /> A. EMERGENCY LEVEL:0 I in <br /> (Circle One) <br /> B. SOURCE OF INFORMATION Phone: �-�y SCI <br /> Name: 1CjhAA �G l` ��^ f <br /> l a67t4 vt 01 <br /> Company: <br /> ode: <br /> C SC7dZipC <br /> & ^ City <br /> Address: <br /> Designated Employee Name: j <br /> II <br /> Reporting Agency Name: I ( City: Zip Code: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGEu r City or Count <br /> Location: <br /> 2 -� [ ( '-----(Circle One) <br /> (Best Physical scription) � <br /> Time: 2 A It. P-11 <br /> Date of Discharge: <br /> IT Date Notified: <br /> D. RESPONSIBLE PERSON USINESS <br /> . sz? 01 1 <br /> Name of Business. 1.4 Phone: (z �� S�" n EJ <br /> Contact Person: !� ( 't L e <br /> Cit �L��1 C�rZip Code: <br /> Physical Address: 1 )Sc x `�0 2 3 y <br /> City: Zip Code: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: ? <br /> Volume: - <br /> Chemicals: <br /> Circumstances: � <br /> LU eA •20-x" <br /> F. ACTION TAKEN: <br /> SITE DISPOSITION: <br /> Notification of Haz Discharge <br /> CVT 77lYIJNY� <br />