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.AR SAN JOAQUIN COUNTY 0 <br /> NOTIFI !'ION OF HAZARDOUS WASTE DIi -IARGE <br /> HEALTH & SAFETY CODE 2.5180::7_:- <br /> f _oma <br /> A. EMERGENCY LEVEL10 11 <br /> I III PHS-EH LOG # <br /> (Circle One) <br /> B <br /> SOURCE OF INFORMATION �p <br /> Name: LaIll repast- &4,f.d (0-23 ��" - - F Phone: �) <br /> Company: ►�D1�e �'nJtrcnr*�� �± <br /> Address: i2M Fv-,car+K Lk)e.St- C. lil 6t k- S fcc e-- C <br /> Designated Employee Name: 1e Phone: <br /> Reporting Agency Name: # I <br /> Address: <br /> t1 <br /> C.- LOCATION AND DATE OF DISCHARGE <br /> Location: 2. 2 S�- 5• r} / _�t �1 <br /> (Best Physical Des� n) i .y (City or oun Circle One <br /> Date of Discharge: Usk <br /> Date Notified- Time: - -- <br /> % � A ►'� l <br /> D. RESPONSIBLE PERSON/BUST ESS <br /> i <br /> VLL <br /> Name of Business C ;vv �x <br /> Contact Person: e-o f Telephone: 01 - l <br /> Physical Address: 2 2-;r q '' CA 5513 c- P j <br /> Mailing Address: SOK O c G4 134 (� r <br /> E. DESCRIPTION <br /> Type of Discharge: tgawK <br /> Volume: <br /> Chemicals: L 4^,Q- � re, <br /> Circumstances: <br /> -6 <br /> F. ACTION TAKEN <br /> �i <br /> SITE STATUS ! omen, w <br /> Uc� L t- GL amlJ <br /> cLi <br /> r <br /> EH 22 013 (Rev.4/91) iii <br />