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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE - ,l <br /> HEALTH & SAFETY CODE 25180.7 L, <br /> A. EMERGENCY LEVEL: IO[I III PHS-EH LOG #—q - (qy <br /> (Circle One) <br /> B. SOURCE F INFORMATION <br /> Name: A "UJ944 Phone: !� S /-shoo <br /> Company: 66ivsEco L42s Chin �rn� <br /> Address: D. f� SQ// k o C74 < {/Q 2 <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF PI$$CHARGE <br /> Location: -7VI <br /> (Best Physical Description) Ci or County) Circle One <br /> Date of Discharge: c VA/ <br /> Date Notified: ?- / -9/ Time:. 4p—m <br /> D. RESPONSIBLE PERS(?�4/BUS[ SS <br /> Name of Business: ett r-o <br /> Contact Person: _ Telephone: <br /> Physical Address: OOo QQ�,�cdc� —� S c <br /> Mailing Address: O a)C Sei/ •, �$ y d z <br /> E. DESCRIPTION <br /> Type of Discharge: ��i+ <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN_ 14. �oz-fc44�n ..?a�GCec>/ <br /> vo <br /> _➢` 12 <br /> SITE DISPOSITION / Cl <br /> EH 22 013 (Rev.4/91) <br />