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SAN ,IOAQUIN COUNTY <br /> N07IFIc4'+ON OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EiMF-RG£:NCY LEVEL: I R III PHS EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFORILiATION <br /> Name: Phone: <br /> Company <br /> Address: <br /> Designated Employee Name: Phone: L--) <br /> Reporting Agency Name: <br /> Address: -2-bp 'z- \. - L ZQ- <br /> C. LOCATION AND DA'I G OF DISCHARGE <br /> Location: S. ^� <br /> (Hest Physical Description) r County) Circle One. <br /> Date of Discharge: -11 4 4� <br /> Date Notified: rl R 91� Time' oeQ2L <br /> D. RESPONSIBLE ?ERSON/BUS"INESS <br /> Name of Business: C� <br /> Contact Person: so.�- � �3�zEZ tc_ky: Te?eahone• U <br /> Physical Address: ������,,.i j 1�'Z E-\Y- C.�r�. Qi ( � <br /> MaiHn; Address: _R w _ to80Or1 <br /> E. DES=:ION <br /> Type of Discharge: L— <br /> Volume: <br /> Che-mcals: <br /> F. ACTION 7AM4 <br /> i <br /> SITE DISPOSITION <br /> EH i 22 013 (Rev.4/91) <br />