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! <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALT"rI & SAFETY CODE 25180.7 �I , <br /> EMERGEi <br /> ICY L.EVEL: EI III PHS-EH LOG <br /> i{ (Circle One) a <br /> }3. SOURCE OF INFORMATION <br /> Phone: (2Eq 916 - <br /> Name: <br /> Company: <br /> E, y; -.• -, -cam✓ /��/ s.�6 Gi..iS ,� 4S(o/� <br /> Address: S' 3 c = <br /> Phone: (2� <br /> �cY- 3 <br /> E ' <br /> 'g Designated mployee Name:' r_G•�t C"+ 7 <br /> Reporting Agency Name: a. �"•, C_� ►�'a�+1` u <br /> Address: s <br /> C. LOCATION AND DATE OF DISCHARGE <br /> �/ �- C 7G fir' Ct�4! / <br /> Location: (City r County) Circle One <br /> (Best Physical Description) <br /> 11 Dare of Discharge: /t,-, aµ',~— <br /> Date Notified- Time: <br /> I + <br /> E D, RESPONSIBLE PERSON/BUSLNESS ti <br /> Name of Business: <br /> ex�c Telephone: Lu <br /> Contact Person: �. <br /> Physical Address: n '` �'"�`' ` <br /> Mailing Address: <br /> 7— <br /> DESCRIPTION <br /> Type of Discharge: <br /> ' Volume: , <br /> Chemicals: dzea zr <br /> I <br /> CirCE=tances: <br /> ii <br /> F. ACTION TAKEN r r �s <br /> f� <br /> IF <br /> :[ STI'E DISPOSITION Gur16•r,. s:k /� sr T /r ri`s �e .•" <br /> -,i- r (ten C t ..1r i 4!0's'+ i O iirrr� /Z✓ C 3 r. <br /> Y <br /> 2.1122 013 (ReV.4/91) <br />