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SAN JOAQUL COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE D COPY <br /> BE.-kLTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEA,I II III <br /> PHS-EH LOG R l � D 3 <br /> ircle one) <br /> B. SOURCE OF INFORMATION <br /> Name: <br /> ?�. ` hone: <br /> Companv: v, <br /> Address: /'��� i�(a.��` S.� <br /> Designated Employee Name: Phone_ <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> ZS3,SS Hw`( Cl C? A ��M �O <br /> Location: / <br /> (fest Phvsicai Description) (City or County) Circle one <br /> Date of Discharge: fJ J i,%iJn �"��� <br /> Date Notined: 7 % / s/`�a, _Time: I PM <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: pty C t�jC A'�o c�&7r�\ <br /> Contact Person: nn U�L SI N U Phone: a <br /> >0 <br /> Physical address: 2 J �' ✓� �`� Y �g /,,kM <br /> Ylailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: N c r � f G <br /> Circumstances: 45c-4,- 0 <br /> F. ACTION_TAKEN <br /> SITE DISPOSI rI N �S C ��1/�l /�� �✓��� r�C MIT)' <br /> In L <br /> EH 22 013 (Rev. 08/20/98) <br />