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SAN JOAQULN COUNTI <br /> NOTIFICATION OF EJAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 2S 130.7 <br /> A. EMERGENCY LEVE I [I III PHS-EH LOG 9 qq. <br /> V <br /> �rcle one) <br /> B. SOURCE nnOF INFORN NATION <br /> Name: two�J2� ~{- 122�v`2 Phone: (0) <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: Vck k <br /> Address: c.f-1-r Y e"� <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> X33crGI1 �1 / �' � `� <br /> (Best Physical Description) ity r County) Circle one <br /> Date of Discharge: lit V1. �-a <br /> Date Notified: AAd r`( L-\ i I � 1 Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business:/���t ' <br /> Phon <br /> Contact Person: e ' S-2� ' <br /> Physical Address: �'n'van f (`r ``' C) -7 <br /> Mailing Address: i�lo 25 �-��r��� ��rn N <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: IA� <br /> Chemicals:i <br /> Circumstances: <br /> a,-tz�,. <br /> F. ACTION TAKEN <br /> SITE DISPOSITION - <br /> � ccs vA- �sE a-t-r� ( LI�Civt c v Cs�k t-t� w'eS <br /> EH 22 013 (Rev. 04!20/9x) <br />