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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:0 II III PHS-EH LOG �V / <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: c Phone: -3 <br /> Company Sc u1 �C w , . S - I= ff D <br /> Address: <br /> Designated Employee Name: Lyy'i -'f o.S Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: ;2,2, 11 /11 � )i I G <br /> (Best Physical Description) J (City or� gun Circle One <br /> Date of Discharge: <br /> Date Notified: v — 1(' o Time:/`O L m <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: i 1" � ' <br /> Contact Person: S e Telephone: <br /> Physical Address o; 1 i r G 4 <br /> Mailing Address: P U AJC -'5 1, <br /> E. DESCRIPTION <br /> Type of Discharge: E' <br /> Volume: Ftin(l s uzv�� <br /> Chemicals: ¢ `� ° / <br /> Cir <br /> cumstances: <br /> (U-1 U` , ("i f •fir T O <br /> F. ACTION 'fAK�N <br /> c <br /> SITE STATUS <br /> �t <br /> Zxe- <br /> G �'✓l /� <br /> EH 22 013 (Rev.4/91) <br />