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0 SAN JOAQUIN COUNTY 0 <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 /� 0\ IV, <br /> A. <br /> A. EMERGENCY LEVEL:� II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION _/L�� <br /> Name: S1Z—X �T Phone: ZSS-S000 <br /> Company: <br /> Address: oalf �4. -5u4w75 -3o yp <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location:_ IfO5 Al /3Lt.oa��, <br /> (Best Physical Description) Ci or County) Circle One <br /> Date of Discharge: <br /> Date Notified: \,/&, - o, /9p5 Time: <br /> D. RESPONSIBLE PERSON/BUS NESS <br /> Name of Business: �cne�s�o /tea iltxd G'P.S. <br /> Contact Person: zztz&n Telephone: Z/0 _ yZ • �oii <br /> Physical Address: /-;,_;z( a d Z Awx a4- � Q56 9i <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: al isc. <br /> dR Su <br /> F. ACTION TAKEN aZGlGvuc.K evf �e a o� C✓2t�I 41331 <br /> d� <br /> SITE DISPOSITIONS C• P�uQ L8 /�f <br /> f <br /> EH 22 013 (Rev.4/91) <br />