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SAN JOAQUIN COUNTY] <br /> NOTIFICATION OF HAZARDOUS WASTE 1)I5CHARGE J <br /> HEALTH & SAFETY CODE 25180.7 <br /> ail <br /> A. EMERGENCY LEVEL:(51 II III PHS-EH LOG #_ 1'o�? 74e <br /> (Circle One) I1 B. SOURCE OF INFORMATION <br /> Name: toPhone: ZG-D f3F-3 � <br /> Company: s/,A .i1 <br /> Address: I?1c, m qz, >7, C-A- 'ii <br /> Designated Employee Name: iii Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: Z l �'✓f c -c =� , ' rt ' <br /> (Best Physical escription) i` (City or oun Circle One <br /> Date of Discharge: <br /> Date Notified: / q1 Time: <br /> E <br /> D. RESPONSIBLE PERSON/BUSINESS r <br /> Name of Business: •J . C' -v <br /> Contact Person; t �'aS Telephone: Z�f'! L '_3 f� t <br /> Physical Address: I <br /> Mailing Address: co j o___ <br /> E. DESCRIPTION <br /> Type of Discharge: :. . _ - <br /> Volume: <br /> Chemicals• .0 ! <br /> Circumstances: a z-t, <br /> Il <br /> F. ACTION TAKEN_0 S <br /> SITE DISPOSITION L//9- CG✓ti <br /> S.7. <br /> i <br /> k <br /> 1 <br /> EH 22 013 (Rev.4/91) <br /> l <br />