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F • SAN JOAQUIN COUNTY 0 <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: 0II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: ( 97a-.r,�7/ 9 <br /> Company: <br /> Address: <br /> Designated Employee Name: r Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: #01f/) Wa A �- ka ze_ / G <br /> (Best Physical Description) City r County) Circle One <br /> Date of Discharge: - 47,119 <br /> - <br /> Date Notified: Time: / : �z Q o m. <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: }�G <br /> Contact Person: asvV Telephone: (�1 9�� —5 7/7 <br /> Physical Address: <br /> Mailing Address: sG2vvi Ei,Le?�-�xp ClY, 5G//1 la <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: N Q <br /> Chemicals: ate PC /3 s 77Do01(. <br /> Circ <br /> 00 <br /> F. ACTION TAKEN �f_- <br /> SITE STATUS AQ,'Q D <br /> d1rtl �z10 <br /> r <br /> 4,9 <br /> s 14R- j AS EAAil <br /> EH 22 013 (Rev.1/91) <br />