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Jv <br /> U SAN JOAQUIN COUNTY �U U. <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 coop <br /> A. EMERGENCY LEVEL01 II III PHS-EH LOG # <br /> (Circle One) <br />' B. SOURCE OF'INFORMATION <br /> Name: 0 Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: e- act4ri Phone: <br /> Reporting Agency Name: e,n vn <br /> Address:_ 5 N .. <br /> C. LOCATION AND DATE OF DISCHARGEi <br /> Location I d <br /> (Best Physical Descn' ti ) (City o oun )Circle One <br /> Date of Discharge: I A h0 uJ I� j, <br /> Date Notified: fa I I b 193 Time: b-Ir 15 pm <br /> Il, .,....__...__.�._ <br /> D. RESPONSIBLE PERSON/BU INESS - <br /> Name of Business: B F 5 <br /> Contact Person: e- ( IG Telephone: (2_ 3 i 15 <br /> Physical Address: 10"37 �F C <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: L e, <br /> Volume: C n x <br /> Chemicals• <br /> Cir tances: f,i.5" `S m a e. Y.�l --<,6 c . r S <br /> Q u a I el LS c L, ( r 4-t d,, f <br /> F. ACTION TAKEN C�ax- 6 -4aa s ewe Oe <br /> .I' e, <br /> I! :i <br /> SITE DISPOSITION 0 a � I7 (,u q rak' If— <br /> EH 22 013 (Rev-4/91) t, <br />