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SAN JOAQUIN COUNTY / <br /> NOTIFI 'ATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL II III PHS-EH LOG # l I — I <br /> (Circle One) Py <br /> B. SOURCE OF INFORMATION l� <br /> Name:_ 8,, _ Adam Phone: 7Lf 6& Y-166 <br /> Company: ,njor <br /> Address: --:!4i -1- C- „raorA- 1•00,Q ar. osb; MCC" . CQ. 715;)Q9-1 b6 9 <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: R,t roo PA "r 6r4,12-1�n c rsrxAms-� corner)/ r,, <br /> (Best Physical Description) (City 6r County) Circle One <br /> Date of Discharge: " <br /> Date Notified: 5 '3-- T/ Time: jyv <br /> D. RESPONSIBLE PERSON/BUSINE S <br /> Name of Business: �; 'cpue eo4- C'oaS <br /> Contact Person: J; t a I Telephone(: (g//5) z-s6-7 30o <br /> Physical Address: Z30 0 Q �1t 131 a . L,7q [n I I-- <br /> Mailing <br /> cMailing Address: 00ly)�e Y1v <br /> E. DESCRIPTION <br /> Type of Discharge: w <br /> Volume: <br /> Chemicals: cn (' �,• 1 'r0 z rne Yv ep7es , �✓Iv�r �'� <br /> Circumstances: Mo.0oAnr ,,e I re e-,n J <br /> 1 e t / rL <br /> F. ACTION TAKEN o fe'7p qjf �ra �✓�s <br /> 4-,/ o f f o /� crcY <br /> 17C v Ze / C✓t��lS CYs T'� <br /> 4 4✓ <br /> e <br /> / r r/ t/N c/ lam! <br /> S[ E DISPOSITION - ,i �vr & 175e) Al / 6 O . <br /> i g <br /> EH 22 013 (Rev.4/91) <br />