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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180 . 7If � 4 <br /> O / <br /> A. EMERGENCY LEVEL : 0II III PHS-EH LOG # 7 ' DoX <br /> (Circle One) <br /> B . SOURCE OF INFORMA`TION <br /> Name : rf/ l7 z61evr�.li/cte. t ,�� Phone : ( ZO`/ ) Q 0Z,6 <br /> Company: lz4dtl106L7) &5-o6;tV11e&V1W60vn¢��( 1/ c <br /> Address : /963 al # ZoV #�A, !Y5 r �J C/9 g51Z <br /> Designated Employee Name : Phone : �) <br /> Reporting Agency Name : <br /> Address : <br /> C. LOCATION AND DAT OF/DIS CHAIRGE <br /> Location:S�f/05 fiG/r C ? y / // <br /> (Best Physical Description) City or County) Circle One <br /> Date of Discharge : ajn/ <br /> Date Notified : Z - 10 -q T Time : 100ptA <br /> D . RESPONSIBLE PERSON/BUSINESS <br /> Name of Business : n7' C Z 4a6118/E551/ <br /> Contact Person: OZ49 Si 44yC-7n ER/ R. 6164soAlTelephone : Log 5 !F679 <br /> Physical Address : <br /> Mailing Address : D . 3pY( / 77/� S1�xX7onJ GB , <br /> E . DESCRIPTION <br /> Type of Discharge : <br /> Volume : <br /> Chemicals : <br /> Circumstances : a� IE! <br /> ew <br /> F . ACTION TAKEN <br /> YZ <br /> SITE STATUSXYe <br /> EH 22 013 (Rev. 4/91 ) <br />