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n D <br /> SAN dOAQUIN COUNTY � <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 2SZ80.7 <br /> A. EMERGENCY LEVEL:0 <br /> I III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: S j1 ec, t.c3 o Phone: (2b �(r <br /> Company: <br /> Address: ,4, <br /> Designated Employee Name: Phone: ( 6�-.3�,f'� <br /> Reporting Agency Name: <br /> Address: <br /> ti <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: j !F e!a 5 C�1W,08- <br /> (Best Physical Description) T (City o ounty) ' cie One <br /> Date of Discharge: Gens _ <br /> Date Notified: 42-3 f=9 T Time:.D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: c'G k G t <br /> Contact Person: Telephone: Q <br /> Physical Address: <br /> Mailing Address: fo c4C4g�-vA ?q- 5 01 <br /> E. DESCRIPTION , <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: , <br /> 4&.4- <br /> Circumstances: / <br /> F. ACTIONTAKEN <br /> .M.-. <br /> SI'Z'E STATUS <br /> EH 22 013 (Rev.4/91) <br />