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O GS SAN JOAQUIN COUNTY <br /> D NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> ID <br /> A. EMERGENCY LEVEL: 0II III PHS-EH LOG #)(o — 6n9 <br /> (Circle One) <br /> B. SOURCE OFNFORMATION _ <br /> Name: ` Phone: <br /> Company- <br /> Address: !u w -� <br /> Designated Employee Name: ! e /l1 Phone: (�) �,^. 0 <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: air.78 E_ o,4K 57- z�`�Y���oz3 <br /> (Best Physical Descnp`t'on) (City or County) Circle One <br /> Date of Discharge: _Iel c 6-ur- <br /> Date Notified: ^ 20©b Time: <br /> D. RESPONSIBLE PERS N/BUSINESS <br /> Name of Business: L w LL <br /> Contact Person: 4,; - u.. , _ Telephone: (209) 5• $(og <br /> Physical Address: E , #/`/, 5)OCK?8-'J CA 9'524D-5 <br /> Mailing Address: R - <br /> E. DESCRIPTION <br /> Type of Discharge: 116v� s <br /> Volume: <br /> Chemicals: Ga - 1 2-- bCA �ivZEiv6 <br /> Circumstances: y` s <br /> F. ACTION TAKEN ISJEtf� <br /> U � ueF <br /> SITE DISPOSITION - <br /> -Lf/ Dto f <br /> �Za � <br /> P E li.sc✓ <br /> EH 22 013 (Rev.4/91) <br />