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SAN JOAQUIN COUN'T'Y <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE P0HEALTH & SAFEIY CODE 25180.7 <br /> PHS-EH LO <br /> A. EMERGENCY <br /> LEVE <br /> L011 II III C # 'G LI — <br /> (Circle One) <br /> B. SOURCE OF INFORMATION phone: <br />' Name: <br /> Company: !liAG� �:� �,>! 12!2542 - <br /> Address• 41 <br />'+ Designated Employee Name: i Phone: <br /> Reporting Agency Name: _ — <br /> i Address: / �' <br />+ C. LOCATION AND DATE OF Is I GSI, <br /> Location: �f� I ' <br /> (Best Physical Description) (City or un Circle One <br /> Date of Discharge' A)V-A nwA <br /> Date`NotiFed: 7 7�, - <br /> Time: <br /> i ai �F. <br /> D. RESPONSIBLE PERSON/BUSWESS <br /> Name of Business: <br /> Contact Person: <br /> Tele ne: <br />� <br /> Physical Address. r 9 <br /> Mailing Address: /a <br /> E. DESCRaMON <br /> Type o E Discharge. <br /> G A <br /> Vol=e: ,,f <br /> Chemicals: <br /> CiICL1Ilrr15t311Ce5' <br /> F. AG'I'I N TAKEN <br /> Sar DISPOSITION <br /> T= �9 / <br /> - I <br /> i <br /> I <br /> Z14. 22 013 (Re.,.4/91) <br />