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6 SAN JOAQUIN COUNTY 0 <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL I III PHS-EH LOG # <br /> Pircle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name L—Sat,�_Izl t2Lr.A&:-bn% CO. 61d,-GMbd� JZA <br /> Address:,wk r. 414� A6, <br /> C. LOCATION ANDDATE OF DISCHARGE <br /> Locatiom.&.7 a/ L. 0 aa,� L� <br /> (Best Physical Description) ��r County) Circle One <br /> Date of Discharge: 3- 7 <br /> Date Notified: -3— ?=4 Time: 3 PO4, <br /> D. RESPONSIBLE PERSON BU ESS <br /> Name of Business: <br /> Contact Person: - Telephone: C2�J4 2,%/. <br /> Physical Address: 4 -rd r,-.& C--1 Z 7 '6 <br /> Mailing Address: 2,S= 37-C A.4' <br /> z--- Q 7- 2152- �CLN <br /> L. DESCRIPTION <br /> Type of Discharge: 16 eAd A A-aa-zeal <br /> Vol=e: <br /> Chemicals: <br /> Circumstances: 406Lo j"0k=:.xwAr <br /> V <br /> F. ACTION TAKEN J <br /> SITE STATUS <br /> i v <br /> EH 22 013 (Rev.4/91) <br />