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SAN JOAQUIN COUNTY C <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL1 11 III PHS-EH LOG # 22 - I <br /> ( ircle One) <br /> B. SOURCE OF INFORMATION <br /> Name: �Lo,/ b 6A'2/V'5 Phone: � <br /> Company: 8 ,4�Z 'e c-lC�i✓ <br /> Address: 19 I n/✓ e -S7cc1�7h vr}- Gl <br /> Designated Employee Name: C Phone: G �_ <br /> Reporting Agency Name: 1V 07-0 civZ,4 /T f <br /> Address: F, �� ^AO�1. S7L 64, <br /> C. LOCATION AND DATE OF DISCO' ARGEE <br /> Location: / 17 5, ", 4 b�� <br /> (Best Physic4l Description) (City or County) Circle One <br /> Date of Discharge: cl-v <br /> Date Notified: e7- — 9:�2— Time:_ �570 M <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: A e5 T cIC/ -J�— <br /> Contact Person: B 5 Telephone: '- <br /> Physical Address: l / 7 <br /> Mailing Address: 51J4-7W <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: /o iivrc ✓ a n!s <br /> Circumstances: i5;� `L A1 <br /> F. ACTION TAKEN /d'S G de <br /> q Al <br /> /27 Pit <br /> SITE DISPOSITION . /.v 1LL Q- <br /> M � <br /> L f1/lit / <br /> EH 22 013 (Rev.4/91) <br />