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SAN JOAQUIN COUNTY nD M <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 v u <br /> A. EMERGENCY LEVEL II III PHS-EH LOG # F�Z— / L/ <br /> ircle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: �) <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: L� <br /> Reporting Agency Name: —S4 . — <br /> Address: !�/� S ®✓ Sc, To s SoG�k a4� <br /> C. LOCATION AND DATE OF DISC GE <br /> Location: /Z.,� i✓. C.)a / <br /> (Best Physical Description) ity r County) Circle One <br /> Date of Discharge: C w�n.u-.ro . <br /> Date Notified: lo-13 - 9 Time: cru P/11 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: y fir:�, 6rco 171 07/ <br /> Cawncww <br /> Contact Person: �orh,Frva�&ur Telephone: 3/0) 5Z.3 ---C7e76 <br /> Physical Address: l U o o 4e,, e kytJ 6/,2f �� v c c rt- 9 o u n <br /> Mailing Address: �Gna <br /> E. DESCRIPTION / <br /> Type of Discharge: ��� weav,. <br /> Volume: uvu,. 04),M . <br /> Chemicals: <br /> Circumstances: -o a c uve x-J <&r�s� pSs� <br /> F. ACTION TAKEN <br /> SITE STATUS P4 -S J <br /> 2 <br /> EH 22 013 (Rev.4/91) <br />