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'Iwo SAN JOAQUIN COUNTY <br /> NOTiFICAtION OF HAZARDOUS WASTE DISCfIARGE <br /> HEALTH & SAFETY OD E 2180.7 <br /> A. EMERGENCY LEVE II III PHS-EH LOG # tV - C 3� <br /> 1)11 <br /> One) <br /> B. SOURCE OF INFORMATION <br /> Name:_ C yCL / U.ti� „r Phone: (�jq2 <br /> Company: 'i -Tw, <br /> Address: ;1,w2 9T-;z o 1 <br /> Designated Employee Name: r 4ha-r Phone: ge.- <br /> Reporting Agency Name: -9.,/ ��tlatth <br /> Address: s N, <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Description) Cityar County) Circle One <br /> Date of Discharge: <br /> Date Notified: -=717-1-?2 Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: __ �tl�/, ta :��-+�►�.� <br /> Contact Person: r- Lr Telephone: <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: v.J --- <br /> Chemicals: <br /> Circumstances: ?111fi< <br /> F. ACTION TAKEN �2// <br /> I./ .► �T (ZlSJT+. o l��,v7'<.11ffl CWniIL <br /> .. ��• N �i.�' ..<. �,+� SoT� � / ,� -f < It <br /> SITE DISPOSITION G/.+ �. Gvf -r�r, s revs <br /> EH 22 013 (Rev.4/91) <br />