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fiil¢- <br />SAN JOAQUIN COUNTY cc <br />r-~ <br />NOTIFICATION OF HA7.kRDOUS WASTE DISCHARGE �'J <br />HEALTH & SAFETY CODE 25180.7 -, - <br />�. EMERG�TPHS-Zi LAG # <br />(Circle One) <br />3. SOURCE OF INFORMATION <br />Name: Phone: (� <br />Company: <br />Address: <br />Designated Employee Name: Phone: zot vgr-o�3 <br />Reporting Agency Name: Ss . 1 q Cry P <br />Address: 4LIS N S� �oaa u'� S <<�o CS �i 5 -ZD <br />C. LOCATIONAND DATE OF DISCHARGE <br />Location: 7-01 LJ • %' �, / R" -'\ <br />(Best Physical Description) r County) Circle One <br />Date of Discharge: gym" <br />Date Notified: It - 13 - 5'L Time: ?-"00 _ <br />D. RESPONSIBLE PERSON/BUSINESS <br />Name of Business: TycV-\K <br />Contact Person: r�G rr:-t�7 V (Z t _ Telephone: -coo 5=T 9 yz 9/ <br />Physical Address: Z.C9t [g 4 53Gc <br />Mailing Address: P o L3ox 6 S Q` p on E �� 9 s36� <br />E. DESCRII <br />Type of <br />Volume: <br />Chemica <br />Circums <br />c. <br />EH 22 013 (Rev.4/91) <br />