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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL II III PHS-EH LOG # �'�7 <br /> cle One) <br /> B. SOURCE OF INFORMATION <br /> Name: ar /1G� Phone: lD YO 3'ZCa�`1 <br /> Company' P � <br /> Address: <br /> Designated Employee Name: Vln i Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION ANDDATE Of D15C,HARGE <br /> Location: 205_ N- <br /> (Best Physical Desc 'ption) Ci r County) Circle One <br /> Date of Discharge: 2 R q Z <br /> Date Notified: :4 2 Z Time: /0: 0,z) <br /> D. RESPONSIBLE PERSON BUSINE S <br /> Name of Business: roc/-� COY �v <br /> Contac: Person: -J641n Telephone: C 1y8' bo°38 <br /> Physical Address: 0 N ev,n Sim <br /> Mailing Address: n 6o-! (0 L4 900Z-6oq// <br /> E. DESCRIPTION / <br /> Type of Discharge: DYIye� <br /> Volume: �(L a oua� <br /> Chemicals: 42� <br /> Circumstances: AYCA rerwr-srn-fafu�e 2�� �n' �✓� ��1 <br /> F. ACTION TAKENY� �) <br /> SITE DISPOSJTION wao n <br /> EH 22 013 (Rev.4/91) <br />