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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:# II II III PHS-EH LOG # <br /> (C�rcle One) <br /> B. SOURCE O INFORMATION ��� `q�� <br /> Name: �� nr � Phone: t tw , 72 2W 1 <br /> Company <br /> Address: �'.=a'1 I &-na i La-j!a CA R<,719- D�S <br /> Designated Employee Name: Phone: L� <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE / � ^ <br /> Location: h • " <br /> (Best Physical Description) Ciry r County) Circle One <br /> Date of Discharge: Ta u1 L <br /> AG Date Notified: _j o - ;z i - g(a Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: V r , 'C W, Telephone: QL�Tj ` ,2?- 3a7/ <br /> Physical Address: R 19 0 S G-t�' `si It,'a dP SFa G� 9535 <br /> Mailing Address: <br /> E. DESCRIPTION Ifi <br /> Type of Discharge: h <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> l ( <br /> F. ACTION TAKEN :ia n IL COA,4 -C-1 5-1z Q a2e-d <br /> SITE STATUS OC-U6Vr'EZ <br /> '� r t 1 01 ..i <br /> C7 f dak, <br /> EH 22 013 (Rev.4/91) <br />