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4( 0�_ <br /> SAN JOAQU N COUNTY F ; v. .� COPY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25130.7 <br /> A. EMERGENCY LEVEL II III PHS-EH LOG 4 <br /> rcle one) <br /> B. SOURCE OF INFORMATION <br /> Name: teSMA- Phone: ?d) S 3 3 O SSf <br /> Company: <br /> Address: J,t V-7 In-" -sr <br /> Designated Employee Name: Phone: <br /> Reporting agency Name: <br /> Address: <br /> C. LOCATION AMID DATE OF DISCHARGE <br /> Location: 130:5 <br /> GSC` 1 DcJ� C%`S�`Lfl� <br /> (Best Physical Description) City or County) Circle one <br /> Date of Discharge: vc <br /> Date Notified: Tune: <br /> D. RESPONSIBLE PERSONlBUSLNESS <br /> Name of Business: G tC`( 0 F ES ALD A) <br /> Contact Person: D hAK/v Phone: 20q -$'31�- `f I/ <br /> Physical .address: <br /> Mailing Address: -PC'R.-O)S `ISS r-5c`/ I AL ) C�°c 4532L� <br /> E. DESCRIP'T'ION <br /> Type of Discharge::ASOC_ln JLC ( � �1L <br /> Volume: U V_ <br /> Chemicals: D <br /> Circumstances: ,1d=U`I L' 1. 4-ex <br /> ro •w Tc it.ocJ r�-rc Sc-rr1 V`A.��r}�Co IjC4w( <br /> F. ACTION TAKEN, A Isoouse,rs 1^QAQ-e <br /> SITE DISPOSITION <br /> C� �Q OIr�I A, 1[�CoL� \le ACSAMPG <br /> EH 22 013 (Rev. 08!20/93) <br />