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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE / <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:Coll III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: S S Cgo -_.N-e LYAP t—�IS Oar Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: 14Phone: C24 <br /> Reporting A�,gency Name: S.T. !t <br /> 3 Ac/46 <br /> Address: V 1 19Ok Zook <br /> C. LOCATION AND DATE OF DISCHARGEoC�Zti <br /> Location: /b/l N• <br /> (Best Physical Description) (City Coun Circle One <br /> Date of Discharge: e l a z_ <br /> Date Notified: S" Z GZ Time: <br /> D. RESPONSIBLE PERSON/BUSINFSS / ) <br /> Name of Business: Zi4tk " ,l',9A wt y eA-" <br /> Contact Person: Q 7Telephone: V <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> volume: �- <br /> Chemicals: Gl/ <br /> Circumstances: <br /> F. ACTION TAKEN <br /> 6 . t <br /> SITE DISPOSITION 2- raP A46 <br /> EH 22 013 (Rev.4/91) <br />