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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> I E,-kLTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <br /> (Circle One) p <br /> B. SOURCE OF ORMATI N Phone: � 0 7�i— 166 <br /> Name: <br /> M JJ / <br /> Company- <br /> Address: <br /> ompany Address: <br /> Designated Employee Name: . % hon . <br /> Reporting Agency Name: v�I,Aqd V. <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGT _ S <br /> Location: 1 � �jl)! moi. G t ly i S f1/1 f�N , / " <br /> (Best Physical Descpaon) (City or Co ty) Circle Ore <br /> Date of Discharge: �} N K- <br /> Notified: . 1 1 Time:— <br /> DateK'ii G <br /> D. RESPONSIBLE PERSON/BU 2 ESS n <br /> Name of Business: S L4 11 A-4 A q <br /> Contact Person: lJ) A TelephondT� <br /> Physical Address: <br /> Mailing Address: Sai ti v;�r <br /> E. DESCRIPTION I � � <br /> Type of Discharge: V <br /> Volume: l 1 r4 le Vvy ,� +4 <br /> Chemicals: I - L�V- v-ec"e 2 v J <br /> Circumstances: o N P^ _ — <br /> 1 ,� � <br /> RN — �' 4 LL �� cT G� k c%l1 VI <br /> F. ACTION TA <br /> SITE DISPOSITION <br /> roc-, LLI" 1 e. <br /> EH 22 013 (Rev.4/91) <br />