Laserfiche WebLink
SAN JOAQUIN COUNTY � <br /> NOTIFATION OF HAZARDOUS WASTE DISCHARGE' <br /> °HEALTH & SAFETY CODE 25180.7 <br /> III PHS-EH LOG # 3r <br /> A. EMERGENCY LEVEL` III I <br /> cle One) <br /> B. SOURCE OF INFORMATIOQN _ Phone:— 5io �53�- 65D� <br /> Name: Sc.ot�- �d2 E; • <br /> Company: G[v C '' o� Cor,►vY.c+�-ce cx-f . `to. <br /> Address: Z4 OI ► S-(-. h'' oQ,rMOT <br /> C.� <br /> Designated Employee;Name: ' F Phone: [�) <br /> Reporting Agency Name: 4 <br /> Address: - <br /> C. LOCATION AND DATE OF DISCHARGE "rG <br /> Location: Co D �i r1 v)e- <br /> (Best Physical Description) x City 'County) tircle One <br /> Date of Discharge: <br /> I` Date Notified: ! LI Time: v v <br /> ,. , <br /> E D. RESPONSIBLE,PERSON/BUSINESS ` <br /> Name of Business: CI v kX_ k <br /> Contact Person:- Telephone: (-Soo <br /> Physical Address: -Z I of v3eLO-5 Kr; St- [Lill-, •✓ 2ay,4(E a CIS '9(44,'12, rt-,3 <br /> Mailing Address <br /> E. DESCRIPTION' <br /> Type of Discharge: 1(VIIv1A✓ 5U✓f D2hro[eum 1��d.�cx'�✓b�� - <br /> f Volume: � , oo r- <br /> V b ILJ6 2k <br /> Chemicals: al * Gatc-5p- <br /> Circumstances'. 5 4es-h oCa fto,15 - feta x. to 'depvn wet's <br /> �s cr�l(ar�4et3 trn objto+�s ULGLAO.1 34_i_wit t <br /> F. ACTION TAKEN QaglnA �'d" LPIE4S <br /> ✓ <br /> . <br /> SITE DISPOSITION .PeJVO(euyY ' <br /> e k to . w ti <br /> co�.�cc.ti•� ✓u.�tcJ S(4 ` r QvO <br /> r '" yes gf)D/7 <br /> rejM4edCQtbn i/111fC CJLI/ �iil Ot/ <br /> o^'CLL k-A . uai . <br /> - <br /> EH 22 013 (Rev.4/91) <br />