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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 CO <br /> PY <br /> A. EMERGENCY LEVEL: 1, II III PHS-EH LOG # < old—OS 7 <br /> ( rcle One) <br /> B. SOURCE OF INZ ODM�ATION <br /> Name: C 1�, e�( ,t f J T4A;- �t,f Phone: Q�a) q6 F <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: (� <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF pISCHARGE <br /> Location:_12C0 itJ. tt cn, Wet., / <br /> (Best Physica Description) CityDr County) Circle One <br /> Date of Discharge: S �S <br /> Date Notified: I Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: Z M 4L!;v <br /> Contact Person: Gn n nz,CC Telephone: GLO l hZ <br /> Physical Address: 17 SO N, ; ie>r�.ti //7 - 710 -O! <br /> Mailing Address: IyOO ozQ PZ Q ^ t�urnl c ("- 01pZe(p <br /> E. DESCRIPTION <br /> Type of Discharge: &Ctk / Atvri r e„ <br /> Volume: 10 0 <br /> Chemicals: <br /> Circumstance . <br /> F. ACTION TAKEN <br /> v U2 <br /> abli, u c n ( t <br /> SITE STATUS >ti <br /> 'aAAtAZ4 riw 6 <br /> ,tb Z,51-1- <br /> EH 22 013 (Rev.4/91) <br />