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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I IIII ` PHS-EH LOG # <br /> 'Ie <br /> One) <br /> B. SOURCE QF INFORMATION _ <br /> Name: r — Phone: ?Yco <br /> Company: '= - <br /> Address: <br /> t�-- <br /> Address: T E t S^ A rvi bIA n/u n-L 12-e-z. t'r-t- UI SS 3 <br /> " <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DIS HARqE <br /> Location: 01 00 S- C" u La <br /> (Best Physical Description) (City o,County) Circle One <br /> Date of Discharge: <br /> Date Notified: - Time: <br /> D. RESPONSIBLE PERSON BUSINESS <br /> Name of Business: r^ <br /> Contact Person: (1t Telephone: (7,--q <br /> Physical Address: 5,2-S LA)• `i In G4-- • ✓' � a � <br /> Mailing Address: P. a• lf�3 <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: G'dsb I t° C. <br /> Circumstances: t Cc.Z T ( ( ✓b DS 7 art <br /> i ,r - Le Vu 1 I' <br /> -�,vwe- • &5c&.et�j iv-� r�(o►rLtfi/1�. of-(Q S <br /> F. ACTION TAKEN <br /> 2. <br /> SITE DISPOSITION S rS( <br /> ` -�' Ct-f, � -tie jvt�wt• �-. h c.e <br /> " Y i z- `t 4 Sa t <br /> n <br /> EH 22 013 (Rev.4/91) � L. moi- VQ v iOtkS ()C4 c� <br /> -t 7s a-,f <br />