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SAN JOAQUIN COUNTY O[Py <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: CLQ II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company: k-15- ENS <br /> Address: <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: Pk4 S <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 2 8:,k e. r, ,+ W,i c <br /> (Best Physical Description) Ci or County) Circle One <br /> Date of Discharge: Lk,.k .c:�: <br /> Date Notified: \ mac: 0-1 Time: 3.CIC <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: rt r4•,: acs; + C. c t, c ,,c' <br /> Contact Person: ' `}Telephone: `igSo <br /> Physical Address: Z ash c=. E, M,Ic- R cnc Lod: (2A <br /> Mailing Address: semc. <br /> E. DESCRIPTION <br /> Type of Discharge: ''=u c 1 r_,lcct,tir . <br /> Volume: Li,` -z. s <br /> Chemicals: C-rkoc. <br /> Circumstances: <br /> J �Ij <br /> F. ACTION TAKEN <br /> SITE STATUS �i-=--. = Ce `yak- tcdA <br /> L`�r\ ct,c� C\c+C_1c-<1 +-, �r�..�`'t'Y� 'r,u �c:•frr{ 4,t-Fr :'�c-,-t-�t( <br /> F-, i.---r .,..- <br /> c-rc . ..�rc•� �,� ,i J �.�1> c„Y+/cr L'-:y�Z \�1C'C�� <br /> EH 22 013 (Rev.4/91) <br />