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o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTNT m <br /> HLE C6? <br /> 304 East Weber Avenue, 3d Floor, Stockton,CA 95202-2708 <br /> P (209)468-3420•Fax:(209)464-0138• Web:www.co.san-joaquin.ca.us/ehd <br /> FORS _ <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> California Health & Safety Code, Section 25180.7 <br /> EHD LOG C-)9 <br /> A. EMERGENCY LEVEL:U 11 III <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: adQ Phone: <br /> Company: <br /> Address: City: Zip Code: <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: City: Zip Code: <br /> C. LOCATION AND DATE ff DISCHARGE <br /> Location: qA<Q VJ• ( , ftACg / City r County <br /> (Best Physical Descri tion) ircle One) <br /> Date of Discharge: 1 Date Notified: 11/ titi 0 Time: 0 M P.M. <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: a B Phone: (vy ) �• N�'� <br /> Physical Address: tF VN• City: Zip Code: _ <br /> Mailing Address: City: Zip Code: <br /> E. DESCRIPTION <br /> Type of Discharge: i <br /> Volume: 14a <br /> Chemicals: ul <br /> Circumst ces: t m In l i o <br /> i <br /> F. ACTION TAKEN: <br /> aIS Wtv( i 6kv A44 18 1 V <br /> LJu( ( ►n ava " evaQ' <br /> SITE DISPO ITION: <br /> WhVIA <br /> w a V OaNr.��j;c�uant .EHD 22-02-003 �Ie t (10/2/2003 ation of Ha Dis harge <br />