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SAN JOAQUIN COUNTY ^W <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> FA. EMERGENCY LEVEL. I II III H EH LOG # <br /> qj-O� <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: 1<e L o Phone: `(�3'SZ-7Y ce <br /> Company: <br /> Address: 73 <br /> Designated Employee Phone: t ) '16 Y-o33 5- <br /> Reporting Agency Name: HS -F-40 <br /> Address: 4115 ItI. S a.� l a�� S� S x/{�•� l� . <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 16 !500 4oVi15t / �G f/r° <br /> (Best Physical Description) Lrry or County5 Circle One <br /> Date of Discharge: vn /C <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: P7? d ( C <br /> Contact Person: ( /011 Telephone: C__) <br /> Physical Address: lb tico sye- Sol _ i:,/mow i Ilk L.. <br /> Mailing Address: S f <br /> E. DESCRIPTION � <br /> Type of Discharge: Uha�� r� ze� /L/,1,--; �-r�► <br /> Volume: - <br /> Chemicals: <br /> Circumstances: V( Vic <br /> F. ACTION TAKEN12-/0- Pe-- c0 <br /> SITE DISPOSITION61 <br /> _,, �/ ,._�¢• �%c �' �r °" <br /> c zZ <br /> //trfl�/1 C1� <br /> EH 22 013 (Rev.4/91) <br />