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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 !' <br /> y� q <br /> A. EMERGENCY LEVEL: 1 11 III PHS-EH LOG # <br /> ( c1e One) i <br /> B. SOURCE OF INFORMATION <br /> Name: 7X,,/".4s /Vo/lFS Phone: <br /> Company: <br /> Address: l Q i /I M<R ✓i LGC n/Tii�Jtt, �1� �!�lSb( <br /> Designated Employee Name: Phone: (tor S160-3414Zo <br /> Reporting Agency Name: S-*Al Co /I%A-�E,� <br /> Address:_. a X -1-00 Si o���v.✓, - �ISZO/ <br /> C. LOCATION AND DATE OF QISCHA4qE S / <br /> Location: l �o 1 !5- I ! i'ti 7 f{' <br /> 1 (Best Physical pescription) (City or County) Circle One <br /> Date of Discharge: n/K1tOJN/✓ <br /> Date Notified: $'. Do �M <br /> D. RESPONSIBLE PERSON/BUSINESS / <br /> Name of Business: /-) �� v "1/CAC i/, 2 , G`OS2e� 1 .9/ ;.17e5T <br /> Contact Person: ��T .as .e. ti/�.0 ES _Telephone: S/ -7-7 v <br /> Physical Address: <br /> Mailing Address: Lir9 S,,n4 Qs R <br /> E. DESCRIPTION j <br /> Type of Disc arae: U BIZ <br /> Volume: <br /> Chemicals: e+ro 1�e u,A.,.. <br /> Circumstances 54v lZ <br /> AJ 0,1572 <br /> ' e <br /> F. ACTION TAKEN t3it <br /> (�IsST� GdP/e I'17iGwo✓eco oi✓ Zf13_. <br /> I <br /> if <br /> I <br /> L <br /> SITE DISPOSITIOt1 f 11rt2 Si a ese sSvnr 1.� %// b <br /> -zn�-i'.0 � F r �,��.rv�.t N A-�'1 �^/ A.s �'¢�u rz.•zcl b �� � <br /> -�'G•.z GL. V'o r f' � c.� <br /> if <br /> • it t <br /> EH 22 013 (Rev.4/91) <br /> 1 <br />