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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHAR `, r`� <br /> HEALTH & SAFETY CODE 25180.7 �! ,�r�1 <br /> A. EMERGENCY LEVEL:0 R III PHS-EH LOG r#` l02 2 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company: F G L .7✓' 001 mea / <br /> Address: 2Sov S� ,s c a �Ic /a lSz /r <br /> Designated Employee Name: EAnv f .t/� Phone: (�`i ) yG�o33S' <br /> Reporting Agency Name: !!; n � R vin <br /> Address: 94 S N S" m 5 Vo Lc-�C . . C-t . <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: / 5' 6 5 <br /> (Best Physical Description) (City o o Circle One <br /> Date of Discharge: "^J-a 0 <br /> Date Notified: /O - ;2 5- f Z Time: 9'�o • <br /> D. RESPONSIBLE PERSON BUSINESS \ <br /> Name of Business: r C k s on r <br /> Contact ll tr l\c (C-SO-1 Telephone: (24 R5 <br /> Physical Address: 156P�� P seglo ti (S� kLo Zsc-"(0 , LI <br /> Mailing Address: <br /> E. DESCRIPTION <br /> L Type of Discharge: (Jn0,Ave; Y�� VLA &--Ge -(�r <br /> Volume: r \c o <br /> Chemicals: Q t ase 1 i— I�n p 1 k�v�bwt rs� <br /> Circumstances: A <br /> F. ACTION TAKEN 7-7�- 5 �� <br /> r•" q <br /> e 0./ �1 W1. 44 n 17r vie 4'•4 <br /> SITE DISPOSITION T/,s -/c x/41 iC rs? <br /> -7f v i ✓ <br /> 5 c u ` Ll <br /> 2 M <br /> relyl AM.AC- 40 <br /> EH 22 013 (Rev.4/91) <br />