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r <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: 1 II III PHS-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name:— Phone: <br /> Company: G'i �� 76Z' Oti <br /> Address: �p , Sff<- <br /> Designated Employee Name: N ;/, r- F-4 v114 . P2&W Phone: Q::M V(L-1115 7 <br /> �i <br /> Reporting Agency Name: . 5 �tJgQ ur,v a017� f 171-61 10 <br /> Address: 2,:�,O 9 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: Z90E Ly �x,igr,%�y ,4/oG? / i✓� -/ 5%QC1Ul��v <br /> (Best Physical Description) ��57—or County) Circle One <br /> Date of Discharge: 2 0 2 <br /> Date Notified o Zv Time:_ 2 :557 'e" <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: 72 m"L iort/ Telephone: o7v 6.56-55 5 <br /> Physical Address: 3�,��5i5h �nirtov �=2to,uT <br /> Mailing Address: <br /> E. DESCRIPTION J <br /> Type of Discharge: <br /> Volume: -v SSD !/ s <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN Bel <br /> SITE DISPOSITION71-125 <br /> TgoeF 7' <br /> Al- //�i <br /> o v <br /> Ate..� - <br /> a=ir <br /> EH 22 013 (Rev.4/91) <br />