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c - <br /> SAN JOAQUIN COUNTY f��,�1 <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE( f( � <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I [I III PHS-EH LOG # �� 4-5 <br /> (Circle One) <br /> B. SOURCE OF [ FORMATION <br /> Name: Phone: (4L9) <br /> Company: /rr AAA -�zwiff a r irr' <br /> Address:— r?� 3�f �—$fe, kfev, e-A 9s oe/ <br /> Designated Employee Name: TP/7ZA Sash» Phone: (�5 ) Si��_ 3%:-z <br /> Reporting Agency Name-:.g- • „4 e, �� >/�f/a . ,,. �, f r . .._.j-A Ho l�z 7��,rrrn <br /> Address: P0. � 3P 9 Flay CA 9.sae/ <br /> C. LOCATION AND DATE OF D[aS GE <br /> Location: 3//3U <br /> (Best Physical Descr�p' tion) i r County) Circle One <br /> Date of Discharge: <br /> Date Notified: /o/ Time: -f elL oiv <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: /Y�L} CO /% rrc, '9r/ �giLs/lirY�a�B2i 2 G <br /> Contact Person: Aore / ffolyr><c,: elephone: (EEeL) 3,;�7- O/� <br /> Physical Address: 65-oe— 4r,�,_ <br /> Mailing Address: 'Zc <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: o <br /> Chemicals: % <br /> Circumstances: Zr.%/ �/ r�rrc mor <br /> F. ACTI N TAKEN /� r <br /> rP <br /> e i Gi/r <br /> / <br /> SITE STATUS J <br /> P VG <br /> EH 22 013 (Rev.4/91) <br />