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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG #� <br /> ( cle One) <br /> B. SOURCE OF-INFORMATION <br /> Name: �oy 1 � �n Phone: (0�) �25'ZD�S <br /> Company: Lel • lAJ • Zr w t v) <br /> Address: 335 (-?Cagon Aw., SSC A , 1K&1!gj 216 <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 221 O Ccu✓j!24 C�- , Dr P',,- <br /> (Best <br /> L(Best Physical Description) Ci r County) Circle One <br /> Date of Discharge: uiViknt-2,J <br /> Date Notified: R-[Z -q Z Time:_ 9;Oa qrn <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: ---r07n <br /> Contact Person: 76YA Dt2.nt1Q1J Telephone: C21) 'NoZ �oOC3 <br /> Physical Address: Z21 O cL,. - !}r SjDCr<ftY� <br /> Mailing Address: Sd• - <br /> E. DESCRIPTION /� � U5 <br /> Type of Discharge: <br /> Volume: Urn e-rutirv, <br /> Chemicals: aln&-40641,E /0 � <br /> Circumstances: Revdw i1e�.� P�o f� �a C� /�h�w . o .,�� ✓rte— <br /> F. ACTION TAKEN <br /> SITDISPOSITI N /�/ �/ i � <br /> EH 22 013 (Rev.4/91) <br />