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SAN JOAQUIN COUNTY ) t_ <br /> NOTIFI,-ATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: u) II III O r ` PHS-EH LOG #_ X;2- 0�7 <br /> (Circle One <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: L.,, _Phone: feja 44t,¢-J,'66F <br /> Reporting Agency Name:. <br /> Address: y4s . 4(o SSC) <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: ` Y1 , at CLh > ) /,J S-tv <br /> (Best Physical Description) i 'or County) Circle One <br /> Date of Discharge: �— <br /> Date Notified: '4 - .,;� 5�-- 9 = Time: �� o <br /> D. RESPONSIBLE PERSO '/BUSINE <br /> Name of Business: t �L <br /> Contact Person: )Telephone: L� � <br /> 17 7 LO <br /> Physical Address: _ <br /> Mailing Address: D' <br /> E. DESCRIPTION <br /> Type of Dischaz e� r r ( C <br /> Volume: <br /> Chemicals: <br /> Circumstances <br /> OL a <br /> eft a C h iukyzl T <br /> F. ACTION T O <br /> o — <br /> Lv <br /> SITE DISPOSITION <br /> 1 - PV <br /> C <br /> S nC 4J fki ffe n 21ZI(:2 ate' /� C e G�,a D n� <br /> EH 22 013 (Rev.4/91) <br />