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/ltd <br />SAN JOAQUIN COUNTY <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVEL:I@II III PHS -EH LOG # <br />(Circle One) <br />B. SOURCE OF INFORMATION <br />Name: 5 k-�;n iqt!-rrr- Phone: (meq) 4 ( o q� - Lf -TCtc <br />Company: <br />Address:�SLLC, S, Lc fir. ,n' (}- <br />Designated Employee Name: Phone: <br />Reporting Agency Name: <br />Address: <br />C. LOCATION AND DATE OF DISCHARGE <br />Location: 5. da44 <br />(Best Physical Description) (City o Coun Circle One <br />Date of Discharge: S(i�-�a2 <br />Date Notified: <:� I i'i-I GZ Time: <br />loll <br />RESPONSIBLE <br />Name of Business: <br />PERSON/BUSINESS <br />Contact Person: s <br />Physical Address: <br />Mailing Address: _ <br />E. DESCRIPTION <br />� •• �lI,L•DG��'z� <br />Type of Discharge: e --,ti a d.e_s e2n_aL <br />Volume: aa[►ems <br />Chemicals:"r�rL ie -tar" "A Sar,Q Yu-" d -yl nnnn-ce " <br />Circumstances: 0.vr,n A U -s -2t- r ugh Itar-A-Q-d n -i' na ony-f- On run wa." which <br />F. ACTION TAKEN <br />.qiTF T)f SPn.q1TlnN <br />EH 22 013 (Rev.4/91) <br />