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n n <br /> SAN JOAQ�-� COti-:v-� FELE COPY <br /> .40TEFICATION OF EL_kZARDOUS WASTE DISCELARGE <br /> HEA,LTH & SAFETY CODE 24180.7 <br /> A. EMERGENCY LEVEL- E�H III PHS-Fri LOG T <br /> q9 • [Z(O <br /> (Circle one) <br /> B <br /> SOL-RCE OF NFORRNIATION '+ rr � <br /> Name* F �1 Phone: Ob? 46�)–Sq �t� --- <br /> Company: G ) <br /> address: O — YL <br /> Phone: <br /> Desi7enated Ecnofovedame: <br /> Reporting :agency vane: <br /> Address: <br /> C. LOC aTION `rD DATE OF DISCHARGE <br /> lot <br /> Location: Z t C7 C 1�.aE TMo ' G <br /> (Best Ph�-sicai Description) {City Coanty) Circle one <br /> Date of Discharge: UN}L <br /> Tune: <br /> Dare vouned: <br /> D. RESPONSIBLE PERSON"BI1SINESS <br /> Name or Business: <br /> of MPS; <br /> 1814 6.rn <br /> Contac: Person: M11�t �eJ'*�N - Phone: ... <br /> Physical Address: jQ21 J <br /> 'Mailing _address: 5 <br /> i <br /> E. DESCRIPTION <br /> I <br /> T.-pe of Discnar-e: <br /> Volume- <br /> Circumstances: <br /> olume-Circumstances: I <br /> F. ACTION TAKE <br /> I <br /> I <br /> SITE DISPOSITION <br /> Er? 22 0 L= (Rev. 0S _0/98) <br />