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SAN JOAQUIN COUNTY <br /> NOTIf I ATION OF HAZARDOUS WASTE DT§CHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVELII III PHS-EH LOG # <br /> ( ucle One) <br /> B. SOURCE OF INFORMATION IV <br /> Name: Phone: Us4 <br /> Company:��. <br /> Address: <br /> Designated Employee Name:' C, do/ o z— Phone: (tea V(o� 3 yYo <br /> Reporting Agency Name: <br /> Address: -iys .v. <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: Y.Yo i ", <br /> (Best Physical Description) (City or County Circle One <br /> Date of Discharge: /. <br /> Date Notified: S/ s/�_ Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: 24 y66,`d <br /> Physical Address: y.5�o/ <br /> Mailing Address: lep, /gnr SI�or-z-,v,> CH 9_Lz�3 <br /> E. DESCRIPTION r� <br /> Type of Discharge: �i �.� f4�,. zoal <br /> Volume: / <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN <br /> 1i3O. <br /> l7cr�s/L/6[ f as . /r . S/P f�// -oma.->/�.irri;�rci0 .so i/ cvtPu s <br /> [.,i//Al lee 7' Ce C <br /> SITE DjSPOSITION A,14, <br /> e- - z s. PSS r <br /> /T/ Cc�i1i[ N - <br /> G 7 <br /> EH 22 013 (Rev.4/91) <br />