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SAWN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE ` -^ -�' ►� <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL I II III PHS-EH LOG # <br /> ( ircle One) <br /> 3. SOURCE OF INFORMATION <br /> Name: f.-D O N I A Phone: <br /> Company: <br /> Address: D .-1 N -e- e N <br /> Designated E. ployee Nam : Phone: (I(AD <br /> Reporting Agency Name: A j A&" G <br /> Address: r <br /> C. LOCATION ANDDATE�OF D CHARGE <br /> Location: 1-i ''i -i 111- 60,1o,N <br /> (Best Physical Description) (City or Countyj Circle One <br /> Date of Discharge: <br /> Date Notified: Tirna: 0 0 <br /> D. RESPONSIBLE PERSON/BUSINESS �. <br /> Name of Business: b 0 <br /> Contact Person: Of-4 iA Telephone: j <br /> Physical Address: L Go G <br /> Mailing Address: <br /> E. DESCRIPTION t 1 p p <br /> Type of Discharge: <br /> Volume: Wv� <br /> Chemicals: ) z wr.` y <br /> Circumstances: e r ,n <br /> ACTION TAKEN j) V PA, G <br /> SITE DISPOSITIOI`1 r 1�1 f <br /> 19- VVA+tA r e <br /> 14f Ak' i <br /> 12 a <br /> E 122 013 (Rev-4/91) <br />