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SAN JOAQUIN COUNTY <br /> 5 <br /> NOTIFI TION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> 00? <br /> A. EMERGENCY LEVEL:6 it III PHS-EH LOG #� <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name• tu�c.► .»�- Phone: <br /> Company: <br /> Address: 3/6Ce2�e�ri�e. C 2S6; <br /> Designated Employee Name: -Phone: �) <br /> Reporting Agency Name: ' <br /> Address: <br /> C. LOCATION AND DATE OF DZCHARGE <br /> Location: // Aj. 5�: / 7"Di✓ <br /> (Best Physical Description) ety>r County) Circle One <br /> Date of Discharge: ONxfA106 1V <br /> Date Notified: Time: /04— <br /> D. <br /> 04 -D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: <br /> Physical Address: 2.00 L 4 io <br /> Mailing Address: ,dQ,, .,L <br /> E. DESCRIPTION -' <br /> Type of Discharge: <br /> volume: <br /> Chemicals• &ZAAAOuJ —DD 7r <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE DISPOSITION — <br /> EH 22 013 (Rev.4/91) 11 <br />