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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL• I I III F"�—S-EH CO LOG # <br /> cle one <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: Lon 57 -0 90G <br /> Company: <br /> Address: / a C/I- 9'5-3 <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: ����� ������ <br /> C. LOCATION AND DATE y( <br /> Location: `�-jj �_, / <br /> (Best Physical Desc " tion) Ci r County) Circle One <br /> Date of Discharge: <br /> Date Notified: N 1 tq Time: I '• azo �M <br /> D. RESPONSIBLE PERSON/BU$�NESS <br /> Name of Business: 17l l l 296 �l D0 <br /> Contact Person: T— Telephone: (_) <br /> Physical Address: / SfdG�fA� <br /> Mailing Address: /.6-11 Y-- <br /> E. DESCRIPTION /�' <br /> Type of Discharge: 1-ed K 7Y� <br /> Volume: <br /> Chemicals: -WAI <br /> Circumstances: Y lfvf/raa !)b <br /> F. ACTION TAKEN r94,v W AI 5 ,� *,o <br /> vv <br /> S[ SPOSITION I ! <br /> { S a�2 <br /> o� <br /> evcidA C-6 <br /> EH 22 013 (Rev.4/91) <br />