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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180. 7 Py <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG # <br /> (Circle One) <br /> B . SOURCE OF INFORD4ATION <br /> Name : 17 tt A I Phone : (4Z5) B�EL- 869S <br /> Company: C6-1� 5 Co <br /> Address : 4P -Owr� rK 600L� Sc,, C%X `74S' F ' - 090 <br /> Designated Employee Name : Phone : (_) <br /> Reporting Agency Name: <br /> Address : <br /> C . LOCATION AND DATE OF DI�CHARGE / <br /> Location: 74670 L6�� ch <br /> (Best Physical Description) Xity or County) Circle One <br /> Date of Discharge : (M <br /> Date Notified : 11, l Time : (F= 00 .4 • 0 <br /> D . RESPONSIBLE PERSON/BUSINESS <br /> Name of Business : Clt—— 11''�oO� <br /> Contact Person: Telephone: eELC) PfZ - Yk9 S <br /> Physical Address : <br /> Mailing Address : . '51A- <br /> E , DESCRIPTION <br /> Type of Discharge : / ti _ <br /> Volume : <br /> Chemicals : <br /> Circumstances� du- <br /> F . ACTION TAKEN3A cv ^EQ DU - W S ln° c `2 f/kS Cw o� <br /> SITE STATUS S_J . CO . L • O , rte• <br /> (,v • P <br /> EH 22 013 (Rev.4/91 ) <br />