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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: ILII III PHS-EH LOG # 9� ' (2 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (_) <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 4{o'L�' bcty�YncU Je— <br /> (Best Physical Description) i or County) Circle One <br /> Date of Discharge: 0Ak4AyJ r) <br /> Date Notified: a•'7-t-S-+ Time: t 3 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: S)ty,Lct,,.,, Qx>�'Poncfio/l <br /> Contact Person: Bob bt Py\vY0 Telephone: (zoo) 251- 7 l 5 <br /> Physical Address: 19 0 33 W1 s+ VaUe!�j t h )1 v A:j_,D- 10N K-,At W A- Off 03 Z <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: Pe-fro toyv'rl b On-5 <br /> Volume: VVAk Ow,rl <br /> Chemicals: CoQSo(jvu LOVISh h)4enl-.5 <br /> Circumstances: 010Wy SOLI Qk-0 QV'COVULX, �iP k-1 Gtar1+drnLMf1&n ( r) <br /> �ih rr.�la S C.ot�.c�C�Q c�r�r�c, a �vQ- -Kin. Itn.ttnF, a55�5h�2.-� <br /> F. ACTION TAKENtll c.on-Flrrr�� <br /> W t+-h t4fiorcily!.,y QWG.I�1615 Of TV 54A112(Q-S CD I <br /> SITE STATUS -viLOU1 PlacM 6/'l.fD <br /> h Gw.d rM CtC�[l�tXQ lhVeS <br /> pv <br /> r6gotmo t;-e l <br /> Code ,57 Revt�dtan <br /> EH 22 013 (Rev.4/91) <br />