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SAN JOAQUL COb-NTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCELAL (0 [P\47 <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: 16 ii III PHS-EH LOG -Q 'Cl <br /> (Circle one) <br /> B. SOURCE OF INFOEUV ATION <br /> Name: 1 (kC, Phone: <br /> Comp y: <br /> Address: <br /> Designate Emplovee Na e: Phone: <br /> 2n a - <br /> Reporting Agency Name: .� <br /> Address: 3091., Iry,1 O.Z #10 <br /> C. LOCATION Ar�CD ATE OF DISCH.A.RGE <br /> Location: <br /> _Ab� I <br /> (Best Physical Description) �r County) Circle one <br /> Date of Discharge: DA 1F1 � <br /> Date Notified: '01 *7,A— F <br /> Time: <br /> D. RESPONSIBLE PERSON/BUSINESS /�,, - <br /> Name of Business: lGC 64 <br /> Contact Person: w Phone: 2 - <br /> Physic ll Address: r 0 <br /> IMailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: V►'� rt`Zfir� <br /> Volume: 1211 rt <br /> Chemicals: <br /> Circumstances-" ri <br /> F. ACTION <br /> SI D SPOSMON <br /> EH <br /> -- <br /> ftML <br /> EH 22 0l3 (Rev. 03/20/93) <br />