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SAN JOAQUIN COUNTY <br /> NOTIFIQAMON OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL II III PHS-EH LOG # 11-3 -1113 <br /> Lacle One) <br /> B. SOURCE OF INFORMATION <br /> Name: b AV D T- WA c h� I Phone: ( 72 9- 2/al <br /> Company: Df- e, r— r-O 5T z X37 <br /> Address: / iil <br /> Designated Employee Name: 1,Lz Ara 4i4LPhone: <br /> Reporting Agency Name:SA ri Th LAI'N <br /> Address: ZODq � GPI,- <br /> c. LOCATION AjgD DATE OF DII§CHARGE <br /> Location: S�O / 771�,�/9 L {7tJI/a�✓ /2� / /1 <br /> (Best Physic tion) (City or Co ty) Circle One <br /> Date of Discharge: (� NI r,h 0 w hf <br /> Date Notified: —7— 7i1— `) Time: ' oo ft-r-o <br /> D. RESPONSIBLE PERSON/BUSINESS �� s�i¢7/O/✓ <br /> Name of Business: <br /> Contact Person: a /ZrFR D Telephone: <br /> Physical Address: b'D Co.e esu v <br /> Mailing Address: + z <br /> r�aolLGf� A-ic� Ufa gs�37 <br /> E. DESCRIPTION 1�� ( <br /> Type of Discharge: / <br /> Volume: s <br /> Chemicals: el i r,9 GA iz v ISS <br /> Circumstances _( onJ SoiSct �S <br /> f�Ge lyo-el A d-- t S r4-, . ve-w o^/ <br /> G-2 9-y3 <br /> I.-. ACTION TAKEN < 4- <br /> 6 —2-e-3 —23 ` <br /> SITE DISPOSITION e Q se S ktta, 144=A:4 <br /> i i� f <br /> o <br /> R— <br /> I'll 1 22 013 (Rev.4/91) <br />