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t _ <br /> SAN JOAQUIN COUNTY ~ <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> f <br /> r <br /> A. EMERGENCY LEVEL: I J II III PHS-EH LOG #__ y ~y 7 4) <br /> ( Acle One) <br /> B. SOURCE OF INFORMATION <br /> Name: N t qdr-)Lo Phone. Q6 <br /> Company:ro m i; <br /> Address: P 9 x /a <br /> Designated Employee Name: t" I ,2 . Phone: ('L,�) '� _3 q z <br /> Reporting Agency Name:.,�,,� P(j;n.;j !,. n 1_ _ l��C S� U��S- t✓ t-4,L'1 <br /> Address':—E0 , <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location:� Q �F- , L-oo <br /> (Best Physic ascription) (City or Coun ) Circle One <br /> Date of Discharge: _,__, j L7o t1J <br /> Date Notified: 5- ! Z �7 G Time: y' o a <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: � ,. Q ',f- <br /> Contact Person: T.n..� G,- 0��r', c.t,. 1 ' Telephone: YY- S` 0/ i <br /> Physical Address: •�-� s T7oGl� a S-ZA <br /> Mailing Address: A a , B o x -:?,o S S•o . .._ (f, <br /> E. DESCRIPTION <br /> Type of Discharge: V <br /> Volume• -�,�-►..rY-~ <br /> Chemicals: o ^ P-60nf S + <br /> Circumstances: <br /> F. ACTION TAKEN <br /> z . <br /> - fe. <br /> SITE DISPOSITION <br /> a <br /> , - <br /> p 0.� <br /> 6 <br /> EH 22 013 (Rev.4/91) <br />