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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCH&R i t 0V <br /> D <br /> HEALTH & SAFETY CODE 25180.7 FF I L L 11 <br /> A. EMERGENCY LEVEL: 1^I � <br /> I III PHS-EH LOG., 1 / F <br /> (Circle one) <br /> B. SOURCE OF[NFORvIATIO/N <br /> Mame: � 1�.7' dlTa C �!!'A r✓I ��31' Phone: ( ) <br /> Company: <br /> Address: Z 2F So J rrt 91 v",6Rs ty� ��,4 'A 5Z —//Od, -,W,4619 , /L 0�6 <br /> Designated Emplovee Name: Phone: <br /> Reporting Agency Name: $Anl T()A�aIN f�'HS/E/YY7 <br /> Address: <br /> �iJ G <BE2 S To c CTO N A G ti 20'F <br /> C. LOCATION AND DATE OF DISCHARGE <br /> �/ / <br /> Locarion: q50 ���lY� �6 C� 1 /C�i?C lC/bi <br /> (Best Physical Description) Caunrv, xCle one <br /> Date of Discharge: G//C/ " 67 <br /> Date Notified_ .S/ Z 1 q 9 7me: .'CO P,LI <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 4 e0rlt(all& <br /> Contact Person: �t E6�17� PF A)y3F Phone:. 3/ 2 2 O .1—// <br /> Phvsicai Address: .1-2A 5 0-rf 1 (00,—Cd—((440 <br /> Mailing Address: 4r <br /> E. DESCRIPTION <br /> Type of Disci�arge: V'4Ile 104(, A: , C <br /> Volume: AI"XWti" <br /> Chemicals: CA A SON �cT eR CH[�� 1 Lac /N D�/ti'K/NE� a1cCL Oti <br /> Circumsrtances: /fin u��d—�� Di i i SiTC ASSN ss Y�1E ' ion <br /> WAi� AND SOIc SAM P6 f1 wr y- :22V=a 1 A7' j=AC t LI TY J AiCLJPIA*? <br /> WATT SfFruPc�S P� . Oc cLc rt C JELL q- /fora 1A)6, �•4N(< wEflCl ! <br /> F. ACTIONTaKEN eopw&CTsL� <br /> SITE DISPOSITION �J�fFf��' /�SSi>SSILI� T 0 i CA9864 7ET,2A'CNLC2l�� <br /> eCr=D 0 H 5 Nl L C CL IS T L <br /> FsJ i. Ar- s - - w�c r 4n 1� <br /> AR C- 2 3v 0 <br /> EH 22 013 (Rev.0&----tu9s) <br />