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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE C O Py <br /> EALTH & SAFETY CODE 25180.7O <br /> A. EMERGENCY LEVEL�DI III PHS-EH LOG # / (C -07 !Z <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: F Phone: L� <br /> Company: A46iiQ E '74 G <br /> Address: 80T Gr�F�= AVF Goer �4gs�0 <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: 5e:,z/ e.,E3ei4 A-C• el '7S0oI <br /> C. LOCATION AND D OF DISCHARGE <br /> Location: Z-0 am <br /> (Best Physical Description) (�r County) Circle One <br /> Date of Discharge: yLL/9 6 <br /> Date Notified: Time: 5R'-. 56Q• 7 <br /> D. RESPONSIBLE PERSON/ USINESS <br /> Name of Business: --P-idjeC- ALG y <br /> Contact Person: - E Telephone: (wg) zY. - z i 'Z- <br /> Physical <br /> Physical Address: $oZ ct ,. A c4 �S�o <br /> Mailing Address: L G¢ 2'4Z40 <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: 3 <br /> Chemicals: <br /> Circumstances: A/S-4649 w45 oT�F�F/5 a=�CLv4r <br /> F. ACTION TAKEN So�� s Gc6v,�Ei� ��' /Ti✓ r� <br /> SITE STATUS �, s r E/I ��oi5 I /� <br /> /J ��ii •,00c��.E /7�a,( GCi.GL� �i 5�-=-=-��Y�J ra '77 � Gi-,�r�E ` <br /> EH 22 013 (Rev.4/91) <br />