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[ t SAN JOAQUIN COUNTY ..� <br /> NOTIFIC SON OF HAZARDOUS WASTE DCS(,�RGB <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <br /> (Circle One) 4 <br /> B. SOURCE OF INFORMATION Y <br /> Phone: <br /> Name: lY f -�5 A , 5 72-/C <br /> Company: S ��w_ <br /> Address: .�?O9W <br /> Designated Employee'NardE., _ _ Phone: �) <br /> Reporting Agency Name:... _ <br /> Address. <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 2avoo Pe � <br /> (Best Physical e c 'ption) (City o oun Circle One <br /> Date of Discharge: Sr <br /> Date Notified: 3 Time: ,'DCS -1 <br /> D. RESPONSIBLE PERSON/ USIN SS <br /> Name of Business: 4. <br /> Contact PersoJ21Af h-t" Telephone: (Jai ?3 -32-10 <br /> Physical Address: !�Va <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: U',- 7- <br /> Volume• <br /> Chemicals: <br /> Circumstancek C S-r <br /> F. ACTION TAKEN <br /> SITE DISPOSIT ON rcAv c 4 <br /> EH 22 013 (Rev.4/91) <br /> - T" <br />