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UAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> j <br /> A. EMERGENCY LEVEL. C/11 III <br /> PHS-EH LOG # Y a <br /> (Circle One) <br /> B. SOURCE OF INFORMA'I'IO Phone: (T�) *fd'8- 33 <br /> Company* <br /> Address: Phone: L� <br /> Designated Employee Name: <br /> Reporting Agen Name: <br /> Addressx <br /> C. LOCATION AND DATE OF DISCHARGE Ld� <br /> Location: Z 56 9A111 4A <br /> (Best Physical Des 'ptio ) (fir County) Circle One <br /> Date of Discharge: <br /> Date Notifed• Time: <br /> D. RESPONSIBLE PERSON/BUSIN SS <br /> Name of Business: S <br /> Contact Person:- Telephone: io Fq z - 4528 <br /> Physical Address: <br /> Mailing Address: ._ 30K AOO�z Sam 4 9 <br /> J <br /> E �. <br /> . DESCRIPTION <br /> Type of Disc ge: � <br /> Volume: pu- <br /> Chemicals: <br /> Circumstances: r o <br /> 5-rZ;WrA,.1k O(>Er <br /> F. ACTION TAKEN c�� 52,-P,64,26 �-o•�� !i� 9 <br /> + <br /> SITE 11DISPOSITION <br /> 774-- <br /> EH 22 013 (Rev.4/91) <br /> L <br />