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SAN JOAQUL`I COL'YTY� <br /> NO'T'IFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HES TH & SAFETY CODE 25180.7 C 4[p <br /> �. EMERGENCY LEVEL: Q QI PHS-EH LOG = <br /> ( ircle one) <br /> B. SOURCE OF INFOKNAATION <br /> Name: 1 1/e �2G Phone: (Ir1O 370-272 o <br /> Company: o,.L 4 9vSS3- GS Zs, <br /> Address:-7 e� , <br /> Designared Employee Name: Phone. <br /> Reporang Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Locauon: (b�$ t , tt�,onr. e l °� <br /> (Best vEsical Descnpnon) (City or County) Circle one <br /> Date or Discharge: Time: IL.0o4.A. <br /> Dare Notified: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name or Business: - / rd�e/ <br /> Concoct Person: Env �^�^ Phone: 803 'F-7 i <br /> Phvsical address: <br /> (ailing address: Ib220 <br /> E. DESCRIPTION <br /> Type of Discharge: UST <br /> Volume: 6�r <br /> Chemicals: a t <br /> Circumstances Aoid ti� fay-�.. '� .Piva x K• a^ �w <br /> eN� <br /> F. ACTION TAKEN Ul> <br /> SITE DISPOSITION wi.ee <br /> EH 22 0 l3 (Rev. 08/30/93) <br />