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{ TANK <br /> SAN ,TOAQUIN COUNTY U � <br /> copyOTFFICATION OF HAZARDOUS WASTE DISC'�iARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> L:[fl II III PHS- LOG <br /> A. EMERGENCY LEVE <br /> (Circle One) <br /> Sf� <br /> B. SOURCE OF INFORMATION <br /> Name: <br /> �I s4 ate Phone: <br /> Company: <br /> Address: ` <br /> JERRY YOSHIOKA � Phone: 22 468-0335 I <br /> Designated Employee Name= i <br /> Repotting Agency Name: SAN JOAQQIN CouSNTY ENVIRONNENTAL HEALTH <br /> Address' 304 E. WEBER AVE- <br /> C. LOCATION AND DATE OF DISaiARGE <br /> Location: <br /> (Best Physical Descriptioa) ` Ca�or CouAry) Circle One <br /> Dare of Discharge: <br /> Date Notified• q Tune: i� o i�ours <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: +-�c-�,- s <br /> Contact Person: <br /> Telephone: s�o Uz s- 5 32 <br /> Physical Address: <br /> A ����� L'1b1 �usc:on <br /> ry SS 3 <br /> If Mailing Address: <br /> DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: ���t �S v� C`uv ��� LAS r-C.yo��•� <br /> I! <br /> F. ACTION TAKEN L <br /> 4 Tc.y 4 <br /> u <br /> f� <br /> f <br /> I <br /> a , <br /> SITE DISPOSITION <br /> l; <br /> 1 ` <br /> EH 22 013 (Rev.=/91) <br /> 1 <br />