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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE (C0 I J U <br /> HEALTH & SAFETY CODE 25180.7 (((JJJ <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (2d /,,7 f37 � <br /> Company: 4si.,.nucned _- <br /> Address: go/ i t l. iQ o 61: t .M <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: <br /> Address: 4u,-i-g <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: .5 q'fi <br /> (Best Physical Description) ir County) Circle One <br /> Date of Discharge: � -7 -4 <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: A4 De II-n r �1•�.; ._ <br /> Contact Person: Telephone: (2f ) <br /> Physical Address: 6A,QS! <br /> MailingAddress: h i Per-j,7,-c- A,� c3.-;1.- 7 <br /> E. DESCRIPTION <br /> Type of Discharge: 1&m A <br /> Volume: � ,._ <br /> Chemicals: p <br /> Circumstances: ak <br /> 10 :,cam p v <br /> F. ACTION TAKEN d o an w _. c �Zr. 1Q t. L, A � � _ <br /> SITE STATUS ' <br /> r <br /> EH 22 013 (Rev.4/91) <br />