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-F <br /> SAN JOAQUIN COUNTY ' <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> ED <br /> L- Y <br /> lip , <br /> .. <br /> A. EMERGENCY LEVEL91rc' <br /> PHS-EH LOG #le e) <br /> { B. SOURCE OF INFO ATIO <br /> i 4 <br /> Name: f fir/ Phone: ! , <br /> Company: <br /> Address: %DO d.r-, .;'t7— <br /> Designated Employee Name: :Ili Phone: (� <br /> Reporting Agency Name: iIl �I <br /> f Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: S4 / Gv. Gr/ 5y" <br /> (Best Physical Description)' ' (City or County) Circle One <br /> Date of Discharge: <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BIJSIN SS <br /> is <br /> Name of Busine <br /> Contact Person: <br /> I1 Telephone: <br /> 4 <br /> -;X5 P {---� <br /> Physical Address: Il <br /> Mailing Address: d <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: li II. <br /> Chemicals: ' <br /> Circu tan_ces: <br /> Ijii I' } <br /> F. ACTION TAKEN <br /> &W&46 <br /> II �, <br /> SITE STATUS I <br /> III 94:b 11 <br /> l <br /> �I <br /> EH 22 013 (Rev.4/91) <br />