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S�,i� J0AQU7N COUNTY <br /> O CATION OF HAZA�OUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 Lb re��� 5 n <br /> �,• EH LOG <br /> E�RGENCY LEVE I II III C S I h25S <br /> A. ircle one) <br /> -t n f 0 e <br /> B. SOURCE OF INFORMATION <br /> la Phone: <br /> Name` n <br /> rr d r n <br /> Company: .r S r C V d ri�a G'4 <br /> Address: r e_ Phone: <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCI-i.-"RGE � <br /> Location: <br /> Sao <br /> r �� / Ci r County) Circle one <br /> te � <br /> (Best Phy } l� �1� <br /> L( Time: <br /> Date of Discharge: <br /> Date Notified: <br /> D RESPONSIBLE PEPSON/BliSINESS <br /> frog a�'►�cfs g�Lo 5�-Ou <br /> Name ofPhone: <br /> Contact Person: m _ a <br /> Physical Address: <br /> Mailing Address: Z <br /> E. DESCRIPTION <br /> Tvpe of Discharge: <br /> Volume: J t <br /> Chemicals: e G 2 <br /> Circumstances: t-5 a, �f <br /> &5 e UA <br /> F. ACTION TAKEN �D n e — <br /> SITE DISPOSITION <br /> r.:u-)-y n 13 (Rev.08/20198) <br />