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,%W SAN JOAQUIN COUNTY "me <br /> NOTIFICATION OF HAZARDOUS WASTE D[SC'r_>RGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> ?_ EMERGENCY LEVEL: I II III PHS-EH LOG 0 <br /> (Circle One) <br /> 3. SOURCE OF INFORMATION <br /> Name: Phone: (_) <br /> Company: a <br /> Address: 30 5 o E. 5 u kc 11-7- <br /> Designated <br /> l2Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: ;SD�{ "%F—. <br /> 1 LOCATION AND DATE OF DISCHARGE / <br /> Location: 4L �L <br /> (Best Physic Desciption) Ci or County) Circle One <br /> Date of Discharge: <br /> Date Notined: T' <br /> D. RESPONSIBLE PERSON/BUSINESS I n/7 <br /> Name of Business: ""N t�l. "6 1:5y C1 4� j g n-j <br /> Contact Person: ToN sF1:f, Telephone: (249) A54k G�1M <br /> Physical Address: <br /> Mailing Address: ;rs, jQo x /26 l' 53an <br /> C. DESCRIPTION <br /> Type of Discharge: /mss aAvZ <br /> Volume: is <br /> Chemicals: <br /> Circumstances: tl <br /> a a <br /> F. ACTION TAKEN f"/!G G]GKLi1/ jJ <br /> SITE STATUS 12f+if <br /> 1 . <br /> E'� 22 013 (Rev.4/91) <br />