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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 C(OPY <br /> A. EMERGENCY LEVELOI III PHS-EH LOG # 1�jlO — //9 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: <br /> Name: <br /> Company: I rn, MILzc e-- 0 k ""` <br /> Address: 3 S 1 <br /> 9 Designated Employee Name: Phone: (� <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE s C� \ <br /> Location: `4o--Ls- � r o^ / <br /> (Best Physical Description) 'ty r County) Circle One <br /> Date of Discharge: 1,0 <br /> Date Notified: Time: 4-'LG -rr-, <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> 7 7 <br /> Contact Person: YY1a.;v , n S Telephone: (�) `� - `� <br /> Physical Address 015 <br /> Mailing Address: <br /> E. DESCRIPTION L e� <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: �- <br /> CircumstanVs• So c l Say,-� j 1 �-S -4--r-a n•. o. t <br /> F. ACTION TAKEN �� . ►� ", -�-"� (rte zs 62e r ( 0�' <br /> SITE STATUS 2 Ips ee.r• <br /> 0 r� m�►rv,� Sc a �, <br /> F,L r 44\e,,r- t e_ fgjt&j r-eA- <br /> EH 22 013 (Rev.4/91) <br />