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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISC�"GE CIO <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL011 II -III PHS-EH LOG # <br /> Circle One <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: lC�. Lf kJ— S9.S <br /> Company: <br /> Address: L�' C- 9 y-�.33 <br /> Designated Employee Name: Ph e•',-C_L) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OFSCHARGE <br /> Location: <br /> (Best Physical Descriptio (City oo�ty � <br /> cle One <br /> Date of Discharge: ;; <br /> Date Notified: 1 1 x`1119 S Time: 7 ►30 � <br /> i <br /> D. RESPONSIBLE PERSON BUSINESS it I <br /> Name of Business: <br /> Contact Person:' Telephone: 5 r'o ((I•-5S �- <br /> Physical Address: _ 5!� <br /> Mailing Address: <br /> E. DESCRIPTION ! <br /> Type of Discharger <br /> Volume: <br /> Chemicals: i <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> k <br /> r 2 <br /> E-H 22 013 (Rev.4/91) <br /> Ii <br />