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r.► SAN JOAQUIN COUNTY �+ <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG # l <br /> (Circle One) <br /> B. SOURCE OF INFQRMATION <br /> Name: Phone: f5� - 45�-i <br /> Compan <br /> Address: >42Z iti <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHVLRU <br /> Location: 79(4') i n). <br /> (test Physicaldescription) (City or Gounty�Circle One <br /> Date of Discharge- l l (e— <br /> Date Notified: I-< l i r'_ Time:—,-';4-'Cep p <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: IM K i^/1 a <br /> Contact Person: / ("1 01 Telephone: �il L!- 2 7z <br /> Physical Address: �!%d <br /> Mailing Address: F. z <br /> E. DESCRIPTION <br /> Type of Discharge: U 4L � <br /> Volume: InAAz-� — <br /> Chemicals: L.,,.u. <br /> Circumstanc s: (rr -I.rx N r- Lz ., �t 5 i /1 n fiti u <br /> l <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> sA 77, yQ <br /> EH 22 013 (Rev.4/91) <br />