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�• SAN ,TOAQUIN COUNTY ./ <br /> NO IF(CATION OF HAZARDOUS WAST D[SC:-?ARGE <br /> 4RkLiH & SArr IT CODE 25!80.7 <br /> A. <br /> �MERGENI CY Lt'-VEL:nI II III <br /> PHS-EH LOG T 'C/ fO " <br /> (Circe One) <br /> B. Name: � dTION <br /> Phone: <br /> Name: <br /> Company: GrrR��^GG,, <br /> Address: 6 - Phone: ` L ) Z-3 y� <br /> Designated Employee Name: <br /> Reperring Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DLSCHARGE 9 SfOG 1vt� <br /> Location 7 n ) S H (City o County Cirde One <br /> (Bess Physical Desaionan) <br /> Dare of DisC arge: <br /> Dare Nori.aed: 5 / <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: G Telehone 09 <br /> Contact Person: �e w '� t P <br /> Physical Add*ess• <br /> Mailing Address: <br /> DESCLTPTION /� <br /> Type of Discharge: 91-n <br /> volume: <br /> Chemicals: d- <br /> Ciraimstanc`s: <br /> 62 <br /> 1110 <br /> F. ACTION TAIC-N <br /> Slir. D(SPO Mi ON S S e_ SS Yne <br /> Fa 22 013 (Rev.4/9I) <br />