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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 ` <br /> A. EMERGENCY LEVEL�II III PHS-EH LOG # 67/ —aI9 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: L_3 <br /> Company: <br /> Address: <br /> Designated Employee Name: 4kbF Phone: -WS---3Y3,4' <br /> Reporting Agency Name: ca"Aix 4,cUk Seri 1«s , C 14 0 <br /> Address: yys ✓V. S'< <br /> C. LOCATION AND DATE OF DISCHARGE/ <br /> Location: 3cnY I-!! <br /> (Best Physical Description) (City or County) Circle One <br /> Date of Discharge: 6.4 le, <br /> Date Notified: /,2- s-S/ Time: 3;00 p,,.,, <br /> D. RESPONSIBLE PERSON/BUSINESS�1 <br /> Name of Business: K:4on 1)n;�l <br /> Contact Person: L., 0,Lco Telephone: (za) 59f- Z/3 <br /> Physical Address: 3 oy <br /> Mailing Address: _ <br /> E. DESCRIPTION /] <br /> Type of Discharge: zucJ 4 4f 4� c <br /> Volume: 14 1 AI 04I 11 <br /> Chemicals: //,nom <br /> Circumstances: ,� w �% �� ter,tn✓./ r s�aT r <br /> cr r <br /> F. ACTION TAKEN T.Gc 7,5100• r,,./ � <i <br /> .9- -5' B ci ✓ c / // O�4 a <br /> A 5 6 <br /> /1 d9�`c//./ !o✓e/l o� s _ ��lcd ✓lei�` n nN �¢c.L�</lrA <br /> SITE DISPOSITION o/az rel / <br /> �2 �� / o,4 s1r,s1f. IZI-"Y% <br /> -- r -av✓/ !r.7 c✓ CX /+T !o�/+r✓in c��v.J . <br /> EH 22 013 (Rev.4/91) <br />