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.S ry <br /> �+! SAN°JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE . <br /> a HEALTH"'& SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: © II III PHS-EH LOG # _ IS <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: ,?..rr er s r �.�_i ms's t Phone: GL} Z -ST <br /> Company: i'a k- / { <br /> Address: s :2 .1)..7- v z y <br /> Designated Employee Name: Phone: �Ki y���- 3 Y`{ <br /> i <br /> Reporting Agency Name:_ «„ p ,N P� /-e<< /�� S'f _-e <br /> Address: ��'u'� �.:, S 5 ,40c����, <br /> v � C� --- <br /> f <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: �d c!l e 44_) cfc �► CA <br /> (Best Physical Description) City r County) Circle One <br /> Date of Discharge: <br /> Date Notified: . /,F 2- _ Time: yA <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: U SA lsin ) F y" <br /> Contact Person: h mss` =T Telephone: v 3 - <br /> Physical Address: -4vc-k-Ao CA g s zaG <br /> Mailing Address: ,1,v, 4a,4_; <br /> E. DESCRIPTION <br /> Type of Discharge: • z , <br /> Volume: a 01/ - <br /> Chemicals: ccs //�: <br /> Circumstances: ---- <br /> F. <br /> I <br /> F. ACTION TAKEN <br /> i <br /> { <br /> tC; ij <br /> SIVE^ DISPOSITION /P H. 4- IS <br /> 'L s sass 14` '1/ .� v rc r tQs�k <br /> v <br /> EH 22 013 (Rev.4/91) <br />