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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: 111 III PHS-EH LOG # <br /> ( ircle One) <br /> B. SOURCE OF INFORMATION 9�b <br /> Name: DOhnq A ItS� � Phone: (.� 3Z' <br /> Company: G—keo Am i La.Joora.�an:� <br /> Address: 1031 u.s5 4-vz -- t* <br /> Designated Employee Name: Phone: L� <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISC GES <br /> Location: I y01 U) • FrZID, / <br /> (Best Physical D tion) ( i ' r County) Circle One <br /> Date of Discharge: <br /> Date Notified: (0 'Z-�--6tL4 Time: 11 : 3UAm <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: V a Q A <br /> Contact Person: e Telephone: (ZID <br /> Physical Address: I L4 I I il fYP v� m Sfi �faG(�Pa" <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: (ya k- i�� O✓L 1 ) 51 <br /> Volume: <br /> Chemicals: <br /> Circumstances fie✓ti J c t ZSyt S D <br /> F. ACTION TAKEN �� 4QJaa 41---1 <br /> SITE STATUS <br /> t " <br /> EH 22 013 (Rev.4/91) <br />