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Y <br /> �✓ SAN JOAQUIN COUNTY `.► <br /> NOTIFICATION OF HAZARDOUS WASTE DISC M[D <br /> HEALTH & SAFETY CODE 25180.7 LF <br /> A. EMERGENCY LEVEL:0 II III PHS-EH LOG #_ <br /> (Circle One) <br /> B. SOURCE .QF INFORMATI N <br /> Name: „ Phone: C-3 ) �l p� 0 <br /> Company: lt,!P� &-k -/3o f F <br /> Address: Z b 0 3/Z <br /> Designated Employee Name: P one: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location:_ /21 -5. <br /> (Best Physical Description) i or County) Circle One <br /> Date of Discharge: <br /> Date Notified: 66-C- 1f Z-t&,,,w Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 6,:tl <br /> Contact Person: Z c . U7,E6� I° _ Telephone: f <br /> Physical Address: <br /> Mailing Address: • O. 3c-C Z_ T�t$S - 75 � -O 3 k i <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> GAS=rdyrt, _.tom G. <br /> F. ACTION TAKEN <br /> 0 <br /> SITE DISPOSITION <br /> r <br /> EH 22 013 (Rev.4/91) <br />