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U <br /> co SAN JOAQUIN COUNTY <br /> ENV7�iNMENTAL HEALTH DEPARTM�'T <br /> 600 E. Main Street, Stockton, CA 95202 F <br /> (209)468=3420•Fax:(209)464-8392• Web:www-co,san-joaquin.ca.us/ehd <br /> PO <br /> y NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Heal O C7 ction 25180.7 <br /> EHDeO <br /> _ .�.'� . , . „ • LOG#: <br /> GENCY LEVET .T 11 111 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Gta v ..Pco cA_ __ Phone: 6;L57)r 17 k, 3 <br /> Company: ..._. 1571V t r D n!gcrjr �9_ Zit C. . ,._ <br /> Address: Poa 1$ city: Zip Code:- g_ t-[52 <br /> Designated Employee Name: F^ <br /> Reporting Agency Name: <br /> Address: City: Zip Code: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: A LA I Cit r Count <br /> (Best Physical Description) (Circle <br /> Date of Discharge: k _v w v­ Date Notified: -1D Time:' I -% a A•M. <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: s &V I---- " K-65 ZZcc. $ � Te- <br /> Contact Person: Jos f:j' i-• C.4- Phone:( } <br /> Physical Address: �20 lS. W' ka CQ"—City: �'-{� s `Zip Code: <br /> Mailing Address: City: Zip Code: <br /> E. DESCRIPTION <br /> Type of Discharge: L <br /> -Volume-.- ... +=:� <br /> Chemicals• 4 <br /> Circumstances: rG.Src <br /> r rt w e'4 e vt ' <br /> F. ACTION TAKEN: 1 C-10 sc2z . <br /> f , <br /> SITE DISPOSITI N: s e< sti <br /> 1Je5 <br /> eA <br /> S z,- <br /> EHD 22-02-003 Notification of Haz Discharge <br /> 05/04/07 <br />