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{ 1 <br /> SAN JOAQUIN COUNTY! 4 <br /> NOTIFIC�ION OF HAZARDOUS WASTE DI SrLGE s_ <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVE1,0II III :y PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION ' <br /> Name: Phone: <br /> Company: !' <br /> Address: '! <br /> Designated Employee Name: Z,4 Phone: 2�9 -3 Y3f <br /> Reporting Agency Name: <n <br /> Address: VqS N, c <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 3C) �f/ .,4 mac.+, • - - - / _ ,r a� <br /> (Best Physical Description) (City or County) Circle One <br /> Date of Discharge: .� <br /> E <br /> Date Notified: Z.L- s-S/ Ti r=e: <br /> D. RESPONSIBLE PERSON/BUSINESS n R <br /> I Name of Business: c 4 •c� �! �� <br /> Contact Person: L. Telephone: (La) 5 f f- Z 3 <br /> Physical Address: 3 oy ,_ _a�� < 7;11 4 c", f'S3G6 - <br /> Mailing Address: <br /> ;1 <br /> E. DESCRIPTION L /] <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstan/ces: <br /> F. ACTION TAKEN 19'.e- � <br /> -71/41 <br /> t G / { i 4/G► d•/ <br /> /1 d y�c/l. r loves�/on •i` � eve ✓�'�'N�`'}'� s� l��c/' <br /> l� <br /> 'i <br /> SITE DISPOSITION12 <br /> ..i�ira �? ��" f �� �•- <br /> G <br /> ` per-A G 1 .d 11 v�/Po� e / � 741�C <br /> �✓ �y'✓�P � � -Pier C /1/A 6/h3+ r <br /> it <br /> EH 22 013 (Rev.4/91) <br />