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f SAN JOAQUIN COUN 7 <br />NOTIFI'TION OF HAZARDOUS WASTE D�HARGE <br />HEALTH & SAFETY CODE 25180:7 7 - vi <br />i 1 N 14) <br />A. EMERGENCY LEVEL:I II III ;HS -EH LOG # <br />C zrcie One) <br />I' <br />t <br />B. SOURCE OF INFORMATION !�. - <br />Name:.� t '� Phone: q-6 <br />Company: <br />Address: <br />Designated Employee Name: Phone: [ `) <br />Reporting Agency Name: A <br />Address: <br />C. LOCATION AND DATE OF DISCHARGE <br />Location: 5:56-3 S . i r M r +--LJ <br />(Best Physical Desai tion) <br />Date of Discharge: w►z�,,�� <br />Date Notified: 1 �-'t I -I I <br />D. RESPONSIBLE PERSON/BUSINESS <br />Name of Business- <br />Contact Person:Co. C1P I t r <br />Physical Address: 6 c o3 S. <br />Mailing Address: <br />E. DESCRIPTION <br />Type of Discharge: <br />Volume: <br />Chemicals: - <br />Circvrnstances: f <br />F. <br />• <br />(City or ounty a One <br />j. 4 Oa :; a• <br />3 <br />Ln <br />.I� <br />Lqr <br />Tel hone: <br />t — P: bl- ; <br />P <br />EH 22 013 (Re x.4/91) <br />