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SAN JOAQUIN COUNTY •� <br /> NOTIFt-�-w-,�TION OF HAZARDOUS WASTE Dl�(--HARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL. i II III _ ' ' ' PHS-EH LOG # /� ' J� <br /> cle Ore)- <br /> B. SOURCE OF INFORMATION J <br /> Name: �.©r4� /-�- . �)�'I PPJG��� Phone: leo l ZZ' cj <br /> Company: U n G, <br /> Address: ?)00cLvi I <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: -7Zg ,5'. &'mere. 5firee76 / �•� <br /> (Best Physical Description) City r County) Circle One <br /> Date of Discharge: GL-'t k�rZnv--yy <br /> Date Notified: --l2 �/Z Time: // •0 ,hv� <br /> D. RESPONSIBLE PERSO BUSINESS / <br /> Name of Business: Ae 1?0s6 C.iS�Pit�l <br /> Contact Person: a cut Telephone: Gt_Z s-;;7- .00 3/ <br /> Physical Address: 1;55Z -ems t/ov j ,4 <br /> Mailing Address: S0zyy\ .., <br /> E. DESCRIPTION <br /> Type of Discharge: K i �j <br /> Volume: 9- • <br /> Chemicals: <br /> Circumstances: - <br /> /t IZ-�'YJiDv�C <br /> F. ACTION TAKENA/o-a_ �,�� <br /> -L/WIS OSITION ' (�c� h c,' J f•, L� / <br /> r4ol�� ��Z/ /1,77,,/ 4e <br /> Z&1W <br /> 'Vic w CA <br /> EH 22 013 (Rev.4/91) <br />