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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 C 0 Pro <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # 3 -13 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: [2 6 6 r- '7 y <br /> Company: <br /> Address: zs /c � 4 953 <br /> Designated Employee Name: eano✓ a r Phone: (7o 4y8 �33y <br /> Reporting Agency Name: �S <br /> Address: H I S V . S�✓\ m e q ��� <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: ) 4 ti Lf � -i: <br /> (Best Physical Description) (City or County) Circle One <br /> Date of Discharge: n <br /> Date Notified: IC-2- i-3 _ Time: 3\6K p r-1 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: �1 SS vo 1 V v C vtc <br /> Contact Person: ���� i e —� Telephone: (:F) 531- Ji <br /> Physical Address: <br /> Mailing Address: Oce gox i is 9`1//5- 3765 <br /> E. DESCRIPTION <br /> Type of Discharge: J/Ia�Tho/(zccX �e (PcSc mor I <br /> Volume: vh !� <br /> Chemicals: ak4- <br /> Circumst/$/nces: U 7- ( K � -1/-913I • o �5, J/3 <br /> it GY r�C�i .S )CS l Cb N7�✓17,H.G n�c� '� <br /> F. ACTIOI TAKEN <br /> 4 `3 / d 9 -e 15 <br /> SITE STATUS /� �'.�,'�c cu✓e/r1Cc� is aYl �.s �_ irss..r <br /> .Uo ew <br /> EH 22 013 (Rev.4/91) <br />