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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL0II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: C!FJ AAf,¢ Phone: (Lm) S7Z -�ov <br /> Company: 4 6,1?-rt <br /> Address: /0 3/ q5 is A V4 <br /> Designated Employee Name: ei APhone: 2nW&9-o5-z,,=5 <br /> Reporting Agency Name: <br /> Address: /'?'5 /C/- f/I-A `:YB 5=71C. LOCATION AND DATE OF DISCHARGE <br /> Location: /2 6 s. z-, <br /> (Best Physical Description) ony or County) Circle One <br /> Date of Discharge: v wAI <br /> Date Notified: � ev 7 Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: f.�2ci7c�'�-�L _ _ �6 ��_Telephone: (_) <br /> Physical Address: <br /> Mailing Address: y7 SS <br /> E. DESCRIPTION <br /> Type of Discharge: t� i <br /> Volume: <br /> Chemical s• SvG <br /> Circumstances: �l6ai c ScyG ieF�vLti rit/���elv�I/� /C_ <br /> F. ACTION TAKEN iv y <br /> j!� q <br /> SITE DISPOSITION Se-77- <br /> EH 22 013 (Rev.4/91) - - <br />