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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 # 1-�l <br /> e One) <br /> B. SOURCE OFJNFO TION <br /> Name:_ K,0%4 v�Cn Phone: �ZS�ZD�S <br /> Company: t n <br /> Address: 335 6groaan Ate . tt� A• MiAePJ « �ZVO <br /> Designated Employee Name-• Phone: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: ZZ-t 0 t'ourf nd br,re- <br /> (Best Physical 'ption) Ci r County) Circle One <br /> Date of Discharge- <br /> Date Notified: -I Z -OI Z Time: ;00 �r,n <br /> D. RESPONSIBLE PERSON US S pr of Business: <br /> Contact Person: _-- �',0)35 lk-4,�jk Telephone: !o <br /> Physical Address: ZZ I D Caun-hm c 2 far, <br /> Mailing Address: --E. DESCRIPTION / <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: ulhzzAmalz <br /> Circumstances: o <br /> _U5-)- rte, <br /> F. ACTION TAKEN �Qr�1�C /"��w�o✓�- �� d G �� <br /> SITE DISPOSITION ?/ 4g <br /> G <br /> (/ <br /> Y <br /> EH 22 013 (Rev.4/91) <br />