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• SAN JOAQUIN COUNTY `� l <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:, 'II III PHS-EH LOG <br /> ( trcle One) C© [�` U <br /> B. SOURCE OF INFORMATION <br /> Name: i— •- L. Phone: —Cl y/ <br /> Company: r 0 <br /> Address:' 4 C'4, fS - c <br /> Designated Employee Name: +� C Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE p <br /> Location: L500 A1. S l�.u c� GC / S�D Gv✓ <br /> (Best Physical Description) (City or oun Circle One <br /> Date of Discharge: (' ;= t� <br /> Nz— <br /> Date Notified: G - i 7 - Time: JO; 00 rZ,� <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: C <br /> Contact Person: ° Telephone: f12 f6cf,- -R70 <br /> Physical Address , S" <br /> Mailing Address: Sce4-YL- _ <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: u Zk�rc v� <br /> Chemicals c-e%ru� <br /> Cirrclumstanc s. <br /> �Evi:bC�ryuy��i:�e fG�� • .�-r.- ac�ltU,,�a, <br /> F. ACTION TAKEN <br /> SITE DISPOSITION u>C 2 <br /> _p.��CI_)�// ,`-i9,�t 1��, �`.1,G'?�,�,i.�Q� �Q'�J:'.� 94'1i�2 <br /> EH 22 013 (Rev.4/91) • • <br />