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May • 13. 2004 1 : 22PM Neil 0• Anderson & Assoc . No -5090 P. 11 <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: 1 11 III PHS-EH LOG <br /> ( cle One) <br /> B. SOURCE OF INFORMATION <br /> Name:, _. _ Phone: <br /> Address: �— <br /> Designated EmployPhone: ) 31� <br /> Reporting Agency Name: C.m,.t�sT- (a • �EfJ <br /> M Address:Pv <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 17L0 5. Q-Gr.'u.2. <br /> (Best Physical Description) (City e Counry 1.Circle One <br /> Date of Discharge: <br /> Date Notified: Z�Lqp? Time- <br /> D. RESPONSIBLE PERSQ /BUSINESS <br /> Name of Business: d,*wa,l Leo- <br /> Contact <br /> _,eo Contact Person: hAr,��: _ __ Telephone: CL, <br /> J Physic:, Andress: 17zo 5, n.8« <br /> Mari;:; Address: ._SLA <br /> E. DEb.(aNTION ,,r t <br /> ` Type of Discharge: (,rtemuc <br /> Volume: _14,1,.k t <br /> Chemicals: <br /> Circumstances <br /> Qnt <br /> F. ACTION TAXE,N <br /> ZJ � <br /> y �'`�'�• (b�*eQ� /Ln+.tte�i.,�" QL'�CM p�sC-a r-e, _ <br /> SITE DISPOSITION SKtr ca <br /> EFI 22 013 (Rev.4/91) <br />