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SAN JOAQUIN COUNTY Cw <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE co <br /> Lj i <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II PHS-EH LOG # <br /> (CircleOne) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: L� <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: f7�i)1165-013 y <br /> Reporting Agency Name: SGS ,cx-�u\ Cc., L!S- ✓EFS <br /> Address: `1 Ll S i(/• 2) ` <br /> C. LOCATION {AND DATE OF DISCHAR E <br /> Location: 4 901 U 0, / \oU / k2n`' <br /> (Best Physical Description) (gjTyDDr County) Circle One <br /> Date of Discharge: vn known c��✓ //-/�' - �� <br /> Date Notified: i/-/y - Time: /D:oo .70,r <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: rnfc <br /> Contact Person: 5:'r n1 i. ; a.\n ccc L, t N% Telephone: (2°t q -3) <br /> Physical Address: C, i tan e--> S�cic Cs <br /> Mailing Address: <br /> E. DESCRIPTION n/� n <br /> Type of Discharge: V r r-L,� .or;ze-S Mc e4s e- �,ro ni S T Al o;nS 4 ryl'�SOcKs a r <br /> Volume: n <br /> Chemicals: \ems c Y <br /> Circumsta ces:_2�<hsoi 7 _Dam <br /> � G� <br /> F. ACTION TAKEN r? c na o 1A 1412 V 5 T <br /> 1Ce Q✓I mak% Co G <br /> SITE STATQS <br /> 574 440'1 4qm ,tA 44 of h& e'l <br /> m <� <br /> h-e�- J �er <br /> m G — <br /> 4,r-EH 22 013 (Rev.4/91) <br />