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W T <br /> SAN JOAQUIN COUNTY aCD <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG # <br /> Circle One <br /> B. SOURCE OF INFO ATION <br /> Name: Z117d Phone: (j+ 4 70— 7 <br /> Company: r w- <br /> Address: 40 3z & «. � n 7 5--- <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: S <br /> Address: k <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: ^Z// � os.c,w.., / <br /> (Best Physical Desi ption) 19 or County) Circle One <br /> Date of Discharge: g - Z c 4, <br /> Date Notified: - Time: 511 ,30 144-r _ <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: i9 r-ro # 6 o w <br /> Contact Person: 1'&r!, / Telephone: 7b- Tti17 <br /> Physical Address: <br /> Mailing Address: /J 0 /z ��- 0 3 � s��cV �!�R 0 7 o Zr <br /> E. DESCRIPTION <br /> Type of Discharge: k cc.►c <br /> Volume: v - <br /> Chemicals: <br /> Circumstances: A, <br /> Ay, c� <br /> F. ACTION TAKEN 161c� <br /> C14A,",c Oe <br /> / 74 <br /> 2 <br /> i T C,- - <br /> SITE STATUS •/ `n e� tib �x. �cr c�,� �^- { / k'� <br /> EH 22 013 (Rev.4/91) <br />