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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE V -, <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVELO II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: sem:/ Sum /Q is 5 me/fes Phone: -tl9UJ <br /> Company: < ^ (z-C - <br /> Address: i-r2,�i mYrs/� C44 ys3ri <br /> Designated Employee Name: (7 ,-� iPhone: (poi) i�c Y- 3 ti If O <br /> Reporting Agency Name: S T,�a q,��'r/ C, ' uG1,1,� �. �c` S,z„ v:c . . <br /> Address: w5- .�, S/ JOG4U �U S�< F 1cYGo910 r?c /P rt �C u7 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: Soo <br /> (Best Physical Description) r County) Circle One <br /> Date of Discharge: ur,/ca � <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: (2o c/l6- Yy�73 <br /> Physical Address: 5"4 fs Ake, Sfvc,Eh.-". A 9s a o I <br /> Mailing Address: sa ..-w <br /> E. DESCRIPTION <br /> Type of Discharge: uP7 OZ u f/61-2 7sc` <br /> Volume: <br /> Chemicals: oC / lzlz 19/ <br /> � / / f <br /> Circumstances: �^/P �-r �� �`S /�t C///'��f COnsT m/'rcTia/. nil of c/c� <br /> F. ACTON TAKEN Via../<s <br /> SITE DISPOSITION 4Z e'!w s:Zr .1a.r .v <br /> /s� v ! <br /> O <br /> EH 22 013 (Rev.4/91) <br />