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- - SAN JOAQUL`I�Cou',qTy <br /> QF S E Di5Cg. <br /> r RG ILE ���Y <br /> rOTEFICATIO <br /> EE.ALTI .1 & SAFE-rY CODE 25180.7 <br /> a Y PHS-EH LOG <br /> A. EMERGENCY LEVEL:(Circle one) <br /> t <br /> B. SOURCE OF mFo€tLI-TION <br /> u , A.Y Phone: mName: M virD <br /> V d va,n �o c��,215 <br /> Compare 5-}�[,k-far+ <br /> Address: `d31 ShA�N } Phone: i)q--. <br /> 3 Or <br /> Designated EmployeCName: D1Yla Y } eA t <br /> �enc�Nm <br /> ae: SAn Da c <br /> Rddressg �D Ac�E- 3.d F aDr <br /> C. LOCATION-AND DATE OF DISCHARGE <br /> Location: ID 3 3 Chap itv r County) Circle one <br /> (Best Phvsical Description) <br /> out z <br /> Data of Discharge: 'lime:3-I3-D3 <br /> Date Notified- <br /> RESPONSIBLE x <br /> D RESPONSIBLE P Ya,y1 �� Po <br /> � E h-}e✓ r is-ts <br /> vA." TYuc k- Plc za- S.3N21 <br /> dame of Business: Phone: 4!v <br /> Contact Person: Yv f k- qF,Z-Dl� <br /> physical Address: look W ' i <br /> via.iling address: SAS <br /> E. DESCRIPTION <br /> -r.,-pe of Discharge: <br /> a5vlin� D+Gs <br /> Volume: W <br /> Chemicals: AAA <br /> - <br /> Circumstances: - <br /> F. ACTION TAKEN <br /> i <br /> { <br /> E <br /> I <br /> SIZE DISPOSITION <br /> i <br /> I - <br /> E <br />` EH 2'?t}13 (Rev, 08/20193) <br />