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N SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180 . 7 <br /> A. EMERGENCY LEVEL II III PHS-EH LOG r'� � ' �� Z <br /> ( "cle One) <br /> Be SOURCE OF INFORMATION <br /> Name : S , c . Phone : .3l r.. <br /> Company: L ' <br /> Address [ 1 3 i 5 Sf r� / u� v� c� <br /> Designated Employee Name : [ o �7 f47 i R0 i cid -S Phone : Q&YD <br /> Reporting Agency Name : J <br /> Address : <br /> Co LOCATION AND DATE OF DISCHARGE V �� ✓� <br /> Location: % ? G / 11L �� -2:2 L=0n <br /> (Best Physical Description) _ (C�nr County) Circle One <br /> Date of Discharge : <br /> Date Notified : q — I .7 9 Time : c5 ,` 00 <br /> D . RESPONSIBLE PERSON/BU5� INESS <br /> Name of Business : � nW ADD Il 5 +9`c2 f�YY . 0 l <br /> Contact Person: p INI 1 " S Telephone: Gi/�y ) c _ — <br /> Physical Address : ;7 6 /a / �7 ri �1� _ f1G � CO4 9 / <br /> Mailing Address: s � <br /> E. DESCRIPTION <br /> Type of Discharge : <br /> Volume: <br /> Chemicals : a Circumstances : j - " r <br /> 1� <br /> F. ACTION TAKEN / D `9P <br /> SITE DISPOSITION <br /> EH 22 013 (Rev-4/91 ) <br />