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G f-1G-17TJ 61.441"19 rK� i i i <br /> FIMFFICEOIFEM <br /> SAN JOAQUIN COUNTYNOTIFICATIQN OF HAZARDOUS WASTE DISCHAE;HEALTH & SAFETY CODE 25180.7 <br /> HUQpUIN COUNTY <br /> ENGENCY SERVICES <br /> A. EMERGEN LI:V I 011 II PHS-EH LOG #_ <br /> (Circle O�e) <br /> B. SOURCE t OI2MATION i <br /> Name ,��df Leo I Phone: ( _)' <br /> Company: <br /> Address: <br /> Designatedplo ..qe Name: Phone: ( )' <br /> Reporting A en l N'•une: <br /> Address•. <br /> C. T'OCATION D DATEjOF DI GE �( <br /> �,ocation N / <br /> I ( it Pliysi. - don) (City or County) Circle One <br /> pate of Dis arge: 9 <br /> Date Notifi 7 7e 'W Time: <br /> -r-II-7�-•-- <br /> !D. BE'SPONSIB PERN/BUSIIES <br /> Name of B mess- <br /> Contact P n: Telephone: (L-- <br /> physical Ad ress: E, — <br /> Mgling Ad <br /> E. DESCRIPTI N <br /> Type of Disc v <br /> Volume: A3 eA _ <br /> Chemicals• �Gadauaz <br /> � <br /> Circumstanc ;1101W <br /> a= <br /> _ F. ACTION TN <br /> v0 <br /> i <br /> I I <br /> SITE DISPO ION <br /> Ole ' <br /> I. <br /> 1 s <br /> i <br /> — EH 22 013Rev.4/ 1) <br /> j <br /> JUL-10-1995 14:47 93% P.02 <br />