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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> - <br /> EMERGENCY LEVEL: I II III PfH #S-EH LOG <br /> A. �� 69 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: jiPhone: L_ ) <br /> Company: t <br /> Address: <br /> Designated Employee Name: <br /> Phone: Vb 34W <br />! Reporting Agency Name: <br /> I <br /> Address: 0 g �g5 O <br /> C. LOCATION AND JQATE OF DISCHARGE <br /> Location: ( /T 201 <br /> (Best Physical Description) (City o County) ircle One <br /> Date of Discharge: f Jvtkf b LtD n <br /> Date Notified: q& Time: ori 0 q:wti <br /> D. RESPONSIBLE PERSON/BUSINESS l <br /> Name of Business: <br /> Contact Person: Uri V li Telephone: C ) <br /> Physical Address: 1 3 q 9 fv . Ajei a If C.qQ G;z�(-o <br /> Mailing Address: j <br /> T <br /> E. DESCRIPTION <br /> Type of Discharge: �►� <br /> Volume: TIA-) n <br /> Chemicals: 1 <br /> Circumstances: Q { S <br /> .i <br /> F. ACTION TAKEN V—A 'E n p�� u7 _ _�C.� _ <br /> r <br /> k <br /> F <br /> SITE STATUS S �s I riY7� 4 <br /> -h sem. e rn " r.' q en <br /> . <br /> f� a n S 5 Us bcen P.5; <br /> j <br /> i <br /> EH 22 013 (Rev.4/91) <br />