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0\/ SAN JOAQUIN COUNTY • <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I III PHS-EH LOG # y— 7 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: S }le-t` w - na 1 AI"b s Phone: <br /> Company: <br /> Address: 'K'Qj f�,-�( [I�t "� O, �3 r, i-ft'j yn cch�CEJ 963 � <br /> Designated Employee Name: ( _5L` Li, Phone: G <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: / &8 &6 C-"4& )t' :- / S7�OC- i <br /> (Best Physical Description) (City Ora <br /> ounty) Circle One <br /> Date of Discharge: L�yrtyz-ter cjvy <br /> Date Notified: /1-21 Time: /00. oe--)a D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: f�i fC� c G 3t cr via o tia . `71'u�i7�Ge�� Dv f -ktgc �U u <br /> Contact Person: Telephone: )_b �f=% <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: G = <br /> Circumstances: i S <br /> F. ACTION TAKEN <br /> ,� t77"/i 1 moi' �' • t=2a�.� U <br /> SITE STATUS <br /> EH 22 013 (Rev.4/91) <br />