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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVELI II III PHS-EH LOG# _,5 I - 04iq <br /> Qircle one) <br /> B. SOURCE OF INFORMATION <br /> Name: &L - Phone: <br /> Company: �_� r e rr2P t �yU rn n vN <br /> Address: 13 -7 S k� ' /7-1 54t k <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE 44 ``-- <br /> Location: 01 ,Z,5 tA) <br /> (Best Physical Description) i or County) Circle one <br /> Date of Discharge: V n <br /> Date Notified: R Time: / : 00 p� <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: r <br /> Contact Person: x a Phone:_L-;;t-_7) z— <br /> Physical Address: o2S C <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: Lea cJ--- ( r.q, <br /> Volume: LA ,ti <br /> Chemicals: CKr-orntV4 D te.Se <br /> Circumstances ke o f e-,,u n u)e r k c r- [ ri d e s is e <br /> F. ACT ON TAKEN Wks .e. ) rip S r e <br /> Dry 1, W a l r A r e. (-+t <br /> Cj <br /> SITE DISPO1SITION L OL+o.r-o1� tiv.tl U ex- <br /> 4 <br /> r�1 Ica <br /> +4+ t,-� IA� t l I ID Q 1 f1 I O C -tom! <br /> �.PMlP�0.�0N ks ✓�PLesSar4 - <br /> EH 22 013 (Rev. 08/20/98) 4 eco <br />