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`SAN JOAQUIN COUNTY II <br /> . ii <br /> E NOTIFICATION OF HAZARDOUS WASTE' DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 it <br /> A. EMERGENCY LEVEL: II III PHS`-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: a i Phone: C:r�7) -(Gr-0Y oj ; <br /> Company: If <br /> Address: ��v �,�� �, l" C�, - '-�-i t/. cc--4 r -7<��r <br /> Designated Employee Name:_ C_ ra 1 z�- I �i Phone: <br /> Reporting Agency Name:_S o- '�� C-, Ku�1!i`�„ Esc <br /> Address: 5 �k. <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: /&03 5; - „f3- <br /> (Best Physical Description) '� r County) Circle One <br /> Date of Discharge: <br /> Date Notified: A,i�IY z Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 0- Ac r� :�It"l-- n S <br /> Contact Person: .:71. ���-- moo. _. I� Telephone: z Lrs <br /> Physical Address: 9?6 1'. Cl a, Ze, A e311 , <br /> Mailing Address: IC-o -- <br /> E. DESCRIPTION ` <br /> Type of Discharge: .�., r2' f u_ �� yri'�r c� <br /> Volume: <br /> Chemicals: We <br /> Cir umstances: LOSc, rerica-21 <br /> J <br /> tl i <br /> F. ACTION TAKEN :i <br /> II <br /> 11 II <br /> SITE DISPOSITION <br /> II '' <br /> EH 22 013 (Rev.4/91) <br /> jE II <br />