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�- SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 7�1 <br /> A. EMERGENCY LEVELII III PHS-EH LOG # <br /> ( ucle One) <br /> B. SOURCE OF INFORMATION <br /> Name: //Cr w Phone: (2QO <br /> Company: /J Clr>m:11 C_ <br /> Address: `>��� ` <rr1.11k re,51. <br /> Designated Employee Name: C.r o/ oy Phone: (,:L-3 17,(4-3 yun <br /> Reporting Agency Name: /424 /e! <br /> Address: -/-/ 57 .v. 5-7' <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 5!Yo/ 4fc�, 2en145�1 <br /> (Best Physical Description) (City orCounty Circle One <br /> Date of Discharge: _ s/ s/i-7 <br /> Date Notified: S/ s/G.� Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: czIor-e- CLieca <br /> Contact Person: Telephone: (Aj�, da <br /> Physical Address: zl. -o/ <br /> Mailing Address: Ol>. /?nr soy�T s��rk,1v C,9 yew <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: //- <br /> Chemicals: <br /> Circumstances: <br /> ,,/, <br /> F. ACTION TAKEN <br /> h/L/° il <br /> fr ri/ �/.// Cd�r/i sriiri ��� SU i/ Gfi[PR S <br /> SITE DISPOSITION C '> %r / �r cc�> wi-s G•.z a�// <br /> is Lw Gr� wcw i -Y� S <br /> i S <br /> EH 22 013 (Rev.4/91) <br />