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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFE OLS 25180.7 <br /> A. EMERGENCY LEVEL:�I II III <br /> PHS-EH LOG #�J>. 03� <br /> (Circle One) <br /> `I JOAQUIN COUNTY PUBLIC HEALTH SERVICES'. <br /> B. SOURCE OF INFORMATIOItNVIRONMENTALHEALTH OIVISION phone: (¢� <br /> Name: ��L� P O BOX 2009 <br /> Company: f' S 445 N.SAN JOAQUIN STREET <br /> Address: <br /> Designated Employee Name: r .o Phone: <br /> ReportinAgency Name: JJG4t' i1 c- �S�r <br /> Address: vS <br /> x S_L <br /> C. LOCATION AND DATE OF DISCHARGE / Svcic�ri� <br /> Location: /,(o/ /��/� r County) Circle One <br /> (Best Physical Description) <br /> Date of Discharge: ow - <br /> Date Notified: 3 Time: 9,4 m — <br /> D. RESPONSIBLE PERSON/BUSINESS �r _ n c^� � ld <br /> Name of Business <br /> / G!I Lr l�cCSGr� />u //' `. .Pit U c f O <br /> Contact Person: Te1ep one: �� o <br /> Physical Address: ._/2W F- <br /> Mailing Address: a 33 !-D` K 64- <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances i /M �vGt%/1/ a �n r o� 2e-r adr.c4 So A) Pa <br /> � <br /> F. ACTION TAKEN <br /> 9 w 11 // uP <br /> SITE DISPOSIT[ON rur�Gw s'�r G csPsr f f /ar .�� Ersatz 1a eek m• <br /> e 1, L oze ro 26 .•c 1iv�+ i syPa ••••/ �v L� c�/� ao <br /> L � / <br /> ' O isles ✓ 45 K/N <br /> EH 22 013 (Rev-4/91) O <br />