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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> C (Dlb)` U <br /> A. EMERGENCY LEVEL: DI III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: �) <br /> Company: <br /> Address: <br /> Designated Employee Name: cnoe- k ' Phone: zc9 v,6 g--o3-3[i <br /> Reporting Agency Name: �� .� fay 2""% Ca. -At+s - �l�p <br /> Address: Ntl S i Scn <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: z z 7 Z i S. /;,y 17� <br /> (Best Physical Description) ' (City or County) Circle One <br /> Date of Discharge: 1 n1 111 o4111 <br /> Date Notified: 9- 3;, 2- Time: 3,004 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 3 ,M co Tfj c. — p�oz4 <br /> Contact Person: `c c 0„ it an Telephone: Cim) <br /> Physical Address: z Z-r Z <br /> Mailing Address: p1�Mp�< o:l C. 7Zb0 M c ,,elc- C\� <br /> ca_ gyroao <br /> E. DESCRIPTION <br /> Type of Discharge: /6,/1. [e <br /> Volume: <br /> Chemicals: <br /> Circumstances:_ -17�C- <br /> F. ACTION TAKENCIL <br /> � Q 1 e- <br /> /i+.�/.K .�i,1yrn dD/�ce i✓+s •'sSVCo� fo Ytic <br /> SITE DISPOSITION <br /> �Me,4i T?on .n <br /> 2 t`ovlaM //-y�THf/ /�41i(oS YY 4 o.�J [ /•`// .�G <br /> / P/r S�L//✓ / �P fC <br /> EH 22 013 (Rev.4/91) <br />