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TIL <br /> ~SAN JOAQUIN COUNTY �''� .� <br /> TION OF DOUS � <br /> NOTIF[CAHEALTH & SAFETY CO E 25 80.7 DISCHARGE <br /> O - <br /> U" <br /> A. EMERGENCY LEVEL:Q II III PHS-EH LOG # 99— 2SD <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: 10c Cc /P// C„ !. Phone: si.0 <br /> Company: <br /> Address: / /u d A� .5o '1ti y D ' 149a c C,� .� �� 9 vs s s <br /> Designated Employee Name: Phone: ('Zai 4�cY .3 ti f D <br /> Reporting Agency Name: S � , <br /> ".g 'r t 1,c %-�et-4, e . <br /> Address: yvs nJ S JOG r� S / S �e7 rA 4t 10 /?c^ rP�x ac u� <br /> C. LOCATION AND DATE OF DISCHARGE CA <br /> Location: ivgv� E. <br /> (Best Physical Description) (City or Counrq Circle One <br /> Date of Discharge: <br /> Date Notified: y/,?/-1_3 Time: /.a o� <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 0 o ,4es i 1/o ✓Lt c� /c <br /> Contact Person: Telephone: (a-u±) y y- 7 vo <br /> Physical Address: <br /> Mailing Address: 51 •�� <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: .✓ ,, wn <br /> Chemicals: 64 so/Zp <br /> Circumstances: Sson/e reru�r ��, �Pn� � �P c11� 1� pow ., �Kk <br /> F. ACTION TAKEN Tr n41 r re 671 wQA S1 ! 5 <br /> SITE DISPOSITION <br /> a „<c•i .. a nr- <br /> GI-I 22 013 (Rev.4/91) <br />