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SA��1 jOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS W DISCI ARGE <br /> HEAT,-i`'rI e& SAFM CODE 25180.7 (C C())P <br /> F-MI ERGENCY LEVEL: I II III <br /> pHS•EH LOG 4 <br /> (Circle One) <br /> ;. SOURCE OF tNFORMATION phone: Lol 57Z- 0900 <br /> Name: 1De)r%nS Ploy c• <br /> Company: Ca f�,b�xr! ,� C� <br /> Address: 0 K Phone: -- <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF <br /> DIS <br /> ShC�G .#. / CbC,f�i <br /> Location: ( r County} Circle One <br /> (Best Physical DesIcriptio � <br /> Date of Discharge: Time: <br /> Date Notified` 1' <br /> D. RESPONSIBLE PERS t USi0E re- <br /> Name <br /> � <br /> Name of Business: Telephone: Z <br /> Contact Person: <br /> Physical Address: t <br /> Mailing Address: <br /> E. DESCRIPTION ha K <br /> Type of Discharge: <br /> f�= <br /> U4n <br /> ls: <br /> tances: <br /> F. ACTION TAKEN <br /> SITE D[SPOSITION T I �Crce, <br /> 6Y� lLr� or <br /> =-meg , <br /> X <br /> EH 22 013 (Rev-4/91) <br />