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SAN JOAQUIN COUNTYC nn •� <br /> wP'TTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:g II III <br /> PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: - <br /> Company:._ 'f- G - <br /> Address <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address. <br /> C. LOCATION AND DATE OF.DI GE <br /> Location•. -;/I9 F-7 --7— <br /> (Best Physical Dcription) i y r County) Circle One <br /> Date of Discharge: -,-,4 �,. <br /> ,4 11 - - - <br /> Date Notified: Time:_L <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: IWP /6;-Yy <br /> Contact Person: Telephone: (Z-- ) -,-tiz-J z z Z <br /> Physical Address: -7 =s`r02k 9 C2 <br /> Mailing Address: , / IZ a,. 4-w%4 1_as A, C,4"5 ra 9 ao <br /> E. DESCRIPTION <br /> Type of Dische: <br /> Volume: v,�J�,-4 r - <br /> Chemicals• -- <br /> Circumstances: <W .. -Y f-Qa� r� (a/�c7v �cSE'T� fG cti <br /> Soy riq � <br /> F. ACTION TAKEN y jg.52Qa,,,dn s7�C� -r��y li.As AEi.r�-rteSITE DISPOSITION 2.62K—,,e� 7z;' <br /> .a <br /> EH 22 013 (Rev.4/91) <br />