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SAN J'OAQUIN COUNTY s <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE i <br /> 4 , <br /> HEALTH & SAFETYICODE 25180.7*� <br /> Ij <br /> A. EMERGENCY LEVELI II III I! PHS-EH LOG <br /> ( rrcle One) <br /> E <br /> s <br /> B. SOURCE OF JNFORMATION i[ <br /> Name: CAdr t, man. Phone: r 'c6 : <br /> Company: s_i <br /> Address: P,,?. VIES: ' C4 .. � r <br /> Designated Employee Name: Phone: -? o <br /> Reporting Agency Name: Pte' 14f) E <br /> Address: rAS:c <br /> C. LOCATION AND DATE OF DISCHARGE J;,'��' + <br /> Location: , 5�, E-- �f 11 / �cr k4,-q,,j i <br /> (Best Physical Description) (City or County) Circle One i <br /> Date of Discharge: '�.c• ;+J�w <br /> Date Notified: Time: <br /> If <br /> D. RESPONSIBLE PERSON/BUSINESS f <br /> Name of Business: �!�� <br /> Contact Person: =- -—4-,eAF Telephone: i �' <br /> Physical Address: 5�� F ��* ate-►`� f' �c-+r�► <br /> Mailing Address: ,f?�'. fox Shvc <br /> ti <br /> E. DESCRIPTION - <br /> Type of Discharge: U Iq <br /> Volume: <br /> Chemicals: O•Ps�/ t�u t �� i <br /> Circumstances: a ,rt1�• e•5-e'Tf TPre��tS' P �Lr'� trr <br /> F. ACTION TAKEN 1.�/t GST; ri�sr '� /,�,�/.;•► ,�pryrtc <br /> A � <br /> SITE DISPOS TION AArj r��,fco,�. f�' Sr C.IxrL <br /> I� P <br /> e <br /> EH 22 013 (Rev.4/91) <br /> it �� <br />