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SAN JOAQUIN COUNTY <br /> NO <br /> T[FICATION OF HAZARDOUS WASTE DIARGE C n[D <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: i l III PHS-EH LOG # 9J3"- 0 V4 <br /> (Circle One) <br /> B, SOURCE OF INFORMATION <br /> Phone: �,. <br /> Name. <br /> Company: i <br /> Address:,, /d 1-14S4A ye: e'!5-M 4 - <br /> Designated Employee Name: Phone: (.,_} <br /> Reporting Agency Name- <br /> Address: <br /> e•Address• T <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location:_ J/d - • <br /> ,(Best Physical Des 'ption) &tTpbr County) Circle One <br /> Date of Discharge: wxj <br /> Date Notified: Time:_ qD. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: Zit <br /> Physical Address: /a A: 40v72 <br /> • a. Z <br /> Mailing Address: ra cam= vFd '2'20- <br /> E. DESCRIPTION <br /> Type of Discharg . v <br /> Volume: <br /> Chemicals: <br /> Circumstances: v. <br /> F. ACTION TAKEN <br /> SITE DISPOSITION a-iGG Bw ASD --74-:' <br /> 0V 91 i <br /> O <br /> Gv <br /> EH 22 013 (Rev.4/91) <br />