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SAN JOAQUIN COUNTY <br /> NOTIFICAA OF HAZARDOUS WASTE DISC#GE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG # ��- O 77 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: 7, � s - , /,-" -1 </ Phone: (.ZL)) V6•,� -396 y <br /> Company: r;,. /�7 <br /> Address: > > �-e V/,- , <br /> Designated Employee Name: w/ c Phone: ?, y�5'f�yy� <br /> Reporting Agency Name: S� _ � , 6/ tie- r'✓� . r <br /> Address: u s ti. <br /> C. LOCATION AND DATE OF DISCH�IRGE <br /> Location: / <br /> (Best Physical Description)' (City di County) Circle One <br /> Date of Discharge: s v- s.z <br /> Date Notified: s-s i ? Time: z vzr <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business <br /> Contact Person: Telephone: :'C" <br /> Physical Address: �,s-e < <l� <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume* c wQ <br /> Chemicals: -5 <br /> Circumstances: .Jn',/o <br /> 0/1'N c7nou ✓� <br /> F. ACTION TAKEN <br /> /� N1 a "r--I U <br /> SITE DISPOSITION 51_L ;// 6e se r_v e S �e �m // ,• <br /> SSG <br /> -� c/vlc-, ra. . :N -u.v� d- P,t' ✓.,-'— n� i� hLi �,. - �i�3 �S � <br /> ( a <br /> l <br /> EH 22 013 (Rev.4/91) <br />