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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 "00A <br /> A. EMERGENCY LEVEL�II III PHS-EH LOG # P <br /> ( rcle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: �) <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: y `-I <br /> C. LOCATION AND DATE OF DISCHr RGE <br /> Location: <br /> (Best Physical Description) (City or County) Circle One <br /> Date of Discharge: <br /> Date Notified: F J-97— Time: .) 30 .-1 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: S1© . /G f?77Te Telephone: >%i '5- Y�-5 z <br /> Physical Address: C' eooei-c3 In USS} �s nt, r� r- ISR a i <br /> Mailing Address: 3.4 <br /> E. DESCRIPTION <br /> Type of Discharge: /7,-,s e 4 74 <br /> Volume: / <br /> Chemicals: a r�rHOiliv:y 5 r/ u Tc „�,�4..•,.ti erlr'U.// O�7J 5/J1i4 Ae. <br /> Circulmss't,/ances: 1l'.� - To/ 15 <br /> Vs/ <br /> T'i![. 7-41t r. i/, C'�fMi/6rya 5 o+%A•J///_� Y'J S/di'..o /4�rr S . <br /> F. ACTION TAKEN -S <br /> rrecAce /-5 <br /> Cb r�wtf n� e� �� lk� rl,n,vlp. ,JM C. A �"� Onc.Q ,r�te.n✓ <br /> 1, r©sy�u 1i -�-� } nom. :., � ttic s/v�,.+�i4•',� � . <br /> SITE DISPOSITION zel. n <br /> L CE e- <br /> EH 22 013 (Rev.4/91) • 0 <br />