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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 _~ <br /> 0 <br /> A. EMERGENCY L L: .I ;II III PHS-EH LOG <br /> ( ' cle One) <br /> B. SOURCE OF INF RMATION <br /> Name: ? r-n A (77 Phone: _ <br /> Company: : <br /> Address: i i- Y ^C(1 rt it n, <br /> r } 7 S <br /> Designated Employee Name: phone: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Description) City or County) Circle One <br /> Date of Discharge: _ i 2-)!, icy ---' <br /> Date Notified: Time: 33"fin-, <br /> D. RESPONSIBLE PEON/BUSIN S <br /> Name of Business.-T, % Pn ' ,; en- I r,,.,- „> <br /> Contact Person: Telephone: <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: ; k <br /> Volume: 1 ,/z <br /> Chemicals: <br /> Circumstances: �`- �• ���.f 1 + <br /> J <br /> F. <br /> ACTION <br /> TAKEN l �� ':�� j !_ ^ �, 1 n <br /> J r 'fit '' �� V 1 i/t 4-1� 1!4�IJ 5r V T^. /• � / _ <br /> • -. 1 '1 l/!' � '�! r`� ^r� 1i I, sir <br /> r <br /> V <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.4/91) <br />