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r � <br />SAN JOAQUIN COUNTY � <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE C 0 <br />Py <br />HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVELpircle <br />II III <br />One) <br />SOURCE OF INFORMATION <br />PHS -EH LOG #� D ! 4 <br />Name: O r l nn l <br />Company: &ZQ 4o&";t5 do <br />Address: P-0-604 6039 <br />Designated Employee Name: <br />Reporting Agency Name: <br />Address: <br />C. LOCATION AND DATE OF DISCHARG <br />Location: 210x3 VV• &,nom <br />(Best Physical Descn* tion) <br />Date of Discharge: - & <br />Date Notified: -2% y <br />RESPONSIBLE PEI <br />Name of Business: <br />Contact Person: _ <br />Physical Address: <br />Mailing Address: _ <br />/)rtvt6 <br />Phone:711 <br />&0 313 <br />Phone:(___) <br />/ Sok tz�) <br />(City r County) Circle One <br />Time: 9' 00 ,4� <br />t eiepnone: � i -T T rj - �/ L -z e-, <br />DESCRIPTION <br />Type of Discharge: <br />Volume: <br />Chemical <br />Circumst <br />F. A�710N TAKE] <br />m <br />EH 22 013 (Rev.4/91) <br />