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SAN JOAQUIN COUNTY <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE ! <br />HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVEL:0 II III <br />PHS -EH LOG # <br />(Circle One) <br />B. SOURCE OF INFORMATION <br />Name: rc��i� G2d� Phone:) <br />Company: SGac.�v-c.J <br />Address: s <br />ployee Name: <br />Designated mPhone: (_) <br />Reporting Agency Name: � <br />Address: <br />C. LOCATION AND DATE OF DISC GE <br />Location: 4 Zy AlyJe� 4� <br />(Best Physical Description) (City or County) Circle One <br />Date of Discharge: mu- . <br />Date Notified: -r z :1 ti Time: 0 19-r1 <br />D. RESPONSIBLE PERSON/BUSINE66 <br />Name of Business:Telephone:/ - 7c3u3 <br />Contact Person: r <br />Physical Address: 47,0 erg <br />Mailing Address: <br />E. DESCRIPTION <br />Type of Discharge: Hau /�wlz� K�c[p "dG <br />Volume: Uri lz= <br />Chemicals: eltA2614 <br />F. ACTION <br />SITE ST <br />EH 22 013 (Rev.4/91) <br />