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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:d� I III PHS-EH LOG # '?3-0 _4 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name:_ ,4-"AliA�<1 Phone: L� <br /> Company- <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: 4/45- IV. 5-4AI ffo a� — <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: SLi nl. op= <br /> (Best Physical Description) P4"r County) Circle One <br /> Date of Discharge: _Z--tV,L'IV6WAI <br /> Date Notified: _C/t4 2�, Time: Z oo o-i <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: _ "T .4 cr7D SAS' <br /> Contact Person: —Telephone: C_) -d 3 <br /> Physical Address: 5G/ E <br /> Mailing Address: r , G .� <br /> E. DESCRIPTION <br /> Type of Discharge: Si�TL L <br /> Volume: lir(e-40w tJ <br /> Chemicals: 014 -7- 5G4-/06-E <br /> Circumstances: 4n,-" dl-jzLAtr-:A IP-1F' r�-<;J�so' ! <br /> �'QZ�/2i✓ on/ �oC i i o� ��oPE.2Tf 4s�S v�s:Ec°L/ <br /> F. ACTION TAKEN A iAJP7rl,_� Td A4-0�' 4e_a s- U� <br /> STTE DISPOSITIONAoE T <br /> Tb AAbO <br /> OL,0�5 <br /> EH 22 013 (Rev.4/91) <br />