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SAN JOAQUIN COUNTY (f <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE (C(D E ` <br /> HEALTH & SAFETY CODE 25180.7 <br /> LF- <br /> A. EMERGENCY LEVEL011 III PHS-EH LOG # 51,:7 / <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: L� <br /> Company: <br /> Address: <br /> Designated Employee Name: _ a r Phone: fZ�`t) Yb�X33 y <br /> Reporting Agency Name: ':�,-,-j (c- <br /> Address: <br /> c .Address: 1-) 4 S X <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: /5�3a e <br /> (Best Physical Description) r County) Circle One <br /> Date of Discharge: <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 5)MCCU \kkt\)�L<< � Scuco C� <br /> Contact Person: �c,c es �tv b vtro/ Telephone: (L2L) fLvy - lfc7 i <br /> Physical Address: IGi32 il! <br /> Mailing Address: ' <br /> E. DESCRIPTION <br /> Type of Discharge: av --kotl z.ej e C <br /> Volume: v e--j 4 <br /> Chemicals: Jlesel <br /> Circumstances: 1 c,Ic-5 gel cm)P-i f 6 qrc w �v'e <br /> F. ACTION TAKEN C* a2- c,,ere /cg�/•� <br /> le <br /> SITE STATUS <br /> pr, ir1/,,� ©�/ <br /> EH 22 013 (Rev.4/91) <br />