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� L , � <br /> ® SAN JOAQUIN COUNTY L"'' <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE �-�.- <br /> HEALTH & SAFETY CODE 25180.7 !-- <br /> A. EMERGENCY LEVEL: CL'II III C�PpyS-EH LOG # <br /> (Circle One <br /> B. SOURCE OF INFORM, ATION <br /> Name: <br /> Phone: <br /> Company: 4v /6 <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name:_S rot (4r� <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: i0 SS' i/a. / <br /> (Best Physical Description) (City o ounty Circle One <br /> Date of Discharge: ,, ;»,✓/' <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: Cr�,l, lc l"ci�sli✓c7I011 e v,-:ew,I./ <br /> Contact Person: 777;-Vic. a Q •'c Telephone: 1a ?SZ -+ s c <br /> Physical Address: ,a Sc:,a <br /> Mailing Address: /o %u X 151 <br /> E. DESCRIPTION C <br /> Type of Discharge: - <br /> Volume: <br /> Chemicals: < 4",e- a.,a/ <br /> Circumstances: ✓� ��riG,vvlc� c � Sc ,,r;e ,ri.+e t�� a.. <br /> �/- ?Z-�/Z- (�c.r t69i4e 17C'� •✓o C v»�6� 4.% :n �..,ir/f- S-�2-Ir t <br /> F. ACTION TAKEN ,.ova/fro/ <-- <br /> i7'<4�7Gy7 <br /> SITE DISPOSITION 'fit :r , ii�c� /v /_ / ["� -� 5, 4 4 <br /> EH 22 013 (Rev.4/91) <br />