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r <br /> SAN JOAQUIN COUNTY Py NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # / rD <br /> ircle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company: fCO /Loa!uvt� �� <br /> Address: P.0 • 60x 60 3R Ar -esc'a% CR 90-?'0 Z' 6,0 3,6 <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: <br /> Address <br /> C. LOCATION AND DATE OF DISCHARG& ' <br /> Location: 2109 v,/. &f111m*i WX& <br /> (Best Physical Description) (City r County) Circle One <br /> Date of Discharge: - <br /> Date Notified: -2 Time: <br /> D. RESPONSIBLE PERSON/BUS[N SS <br /> _ Name of Business: 74 2 13 3 <br /> Contact Person: , a") Telephone: ( ) q7 9- <br /> Physical <br /> Physical Address: 0,0 W <br /> Mailing Address: jd1pul <br /> E. DESCRIPTION � v���.��-�" <br /> Type of Discharge: led K YI � — <br /> Volume: Cin coff n <br /> Chemicals: <br /> Circumstances: <br /> F. AgrION TAKEN D(—,co11-!' Gtl �� • �/1✓. �nq w:�l <br /> SITE STATUS P0 <br /> EH 22 013 (Rev.4/91) <br />