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06/26/97 -THI 14:16 FA.1 583 3282 - — -- <br /> liLTRA4IAR y-.H HORIZON SAC 9003 <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARG <br /> Iw. HEALTH & SAFETY CODE 25180.7 ;? <br /> cc, <br /> y <br /> A. EMERGENCY LEVE • I II III PHS-EH LOG # <br /> (Qle One <br /> B. SOURCE OF INFO ON <br /> Name: 7 Phone: (fJ 0 <br /> ' Company: tZ age-A& <br /> Address: <br /> Designated Employee Name: Phone: U <br /> ' <br /> Reporting Agency Name: <br /> Address: <br /> I C. LOCATION AND DATE OFD iMARGE <br /> Location: . <br /> .(Best Physical Description) /fCitqDr County) Circle One <br /> ' Date of Discharge: ull� <br /> Date Notified: Time: egx,.. <br /> D. RESPONSIBLE PERSOt/BUSINESS, <br /> /Name of Business:. <br /> V <br /> Contact Person: ! Telephone: <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: 6Zis <br /> Volume: <br /> I Chemicals: A <br /> Circumstances: <br /> P <br /> F. ACTION TAKEN (J <br /> y <br /> ISITE STATUS <br /> Aeuda6w�2t Ad7 <br /> t <br /> EH 22 013 (Rev.4/91) <br />