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i <br /> _ SAN JOAQUIN COUNTYf <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> x' <br /> A. EMERGENCY LEVEL: ®II III PHS-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name; :2!5 4W � ' �� �. _ Phone: (pc,)- 4&7- <br /> Company: <br /> &7--Company: Ago5 Ca 7D <br /> Address: I Z Ski- <br /> Designated <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address• 4�15'd- <br /> C, LOCATION AND DATE OF DISCHARGE <br /> Location: Sof &A TGFiRr _ / Lao= <br /> (Best Physical Description) r County) Circle One <br /> Date of Discharge: ''+SAX /4M 'cls Z <br /> Date Notified: AV /S, SRR Z Time:- <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: . ?� <br /> Contact Person: Telephone: (gzj> 4a7— 2 <br /> Physical Address: 17-31-15 S-v,v,wc-.4 9 zo <br /> Mailing Address: t 7 S,S �'�oE® �. -rV s 9s'zv <br /> E. DESCRIPTION <br /> Type of Dischar e: <br /> Volume: G2�a <br /> Chemicals: Cv <br /> Circumstances: GtG Co�l�✓k�i� � e / ^lam .�IE.D <br /> ��o�'lzsG.�✓i sF <br /> F. ACTION TAKEN EG vr� dBS� lE ��/ -vc�-iC.Oo <br /> �►/d r �kySi SITE DISPOSITION <br /> EH 22 013 (Rev.4/91) <br /> I <br />