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SAN JOAQUIN COUNTY f, <br /> NOTIFI•ON OF HAZARDOUS WASTE DIS GE { ` <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL I II III PHS-EH LOG # <br /> ( le One) <br /> B. SOURCE OF INFORMATION <br /> Name: i alJe-�-A gq C I Phone: (#1t,) 3&y- 7&00 <br /> Company: o is �1ri <br /> Address: (-180 uJODd °` f4 /o <br /> Designated Employee Name: /,d- ! t110 P one: :2 9&,5-361,F, <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DAT OF DISCHARGE <br /> Location: /Zy W • t 5�. <br /> (Best Physical Description) (City r County) Circle One <br /> Date of Discharge: 'I l <br /> Date Notified: 8 lqj Time: 7-' /5- 2 n <br /> D. RESPONSIBLE PERSON/BLJ,s INESS <br /> Name of Business: K D:2E <br /> Contact Person: _ . UIi okyyL&t� Telephone: Cwj VIY 1 —/L(L/q <br /> Physical Address: <br /> Mailing Address: P P, /) Anx i110 OJT 20 / <br /> E. DESCRIPTION <br /> Type of Discharge: lea <br /> Volume: G-7� <br /> Chemicals: we <br /> qircumstances: S5 eV i PX1..� �t� <br /> F. ACTION TAKEN <br /> SITE DISPOSITION 0 ST <br /> f�2 .0 an iyL-°c <br /> D C E <br /> EH 22 013 (Rev.4/91) <br />