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.. SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTc DISC-;-ARGE <br /> ?=.Fkl:j--i & SAr== CODE 2Si80.7 <br /> r PHS-EH LOG T <br /> A. ZMERGENCY Ln"VEL:/ II III <br /> c rde One) <br /> B. SOURCE OF INFORMATION <br /> Phone: r70 �7�"09oC� <br /> Name: 625Company. G r� <br /> Address: D �� <br /> Designated Etnpioyee Name: Phone: 20'j) 4A6 <br /> Reporting Agency Name: <br /> Address: <br /> C. LOC.ATION AND DAT? OF DISCHARGF <br /> Location: �7 D (City oiQ�unr, Circle One <br /> (Best Physical Description) <br /> Date of Discharge: <br /> Date Notified: , !' 9 lime: <br /> D. RESPONSIBI= ?ERSON/BUSINESS <br /> Name of Business: C l' <br /> Contact Te?ephane oY <br /> Physical Address: <br /> Mailing Address <br /> DESCR=ON /� K <br /> Type of Discharge: al-n 2d/�a P� <br /> Vciume: <br /> Chemicals: <br /> Circuas.ances: Cr l <br /> ACTION TA= -------------------------- <br /> SI'Z'E 'D[SPO SMIONS S e SS C c — <br /> _ <br /> EH 22 013 (Rev.4/9') <br />