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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE C 0 py <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCYI II III PHS-EH LOG # n n - d0 a, <br /> cle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: <br /> Name: (_� <br /> Company: <br /> Address: <br /> Designated Employee Name: Pone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISC GE <br /> Location: 'S T-AZ7 <br /> (Best Physical cripdon) ( ry County) Circle One <br /> Date of Discharge: w <br /> Date Notified: / Time: t( <br /> D. RESPONSIBLE PERSO USINESS <br /> Name of Business: <br /> Contact Person: Telephone: CwC 424 • G <br /> Physical Address: �3z� �.l ► �M ti.�-� .,_ � `' 9s z o S <br /> Mailing Address: -A v,,-e- <br /> E. DESCRIPTION / <br /> Type of Discharge: p �- <br /> Volume: <br /> Chemicals• <br /> Circumstances: <br /> F. ACTION TAKE1NkAj <br /> — <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.4/91) <br />