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SAN JOAQUIN COUNTY1i <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.71 <br /> A. EMERGENCY LEVEL: I II III PHS-EHi LOG #_22- <br /> --O/q_• <br /> ( cle One) <br /> i <br /> B. SOURCE OF T"'FORMA ON �, li <br /> Name:_Q:; ?�� Zc� v �f; 11 Phone; l � <br /> Company: 11. 4 . <br /> Address: O�`� Vy �'� D <br /> Designated Employee Name: 111 Jl: Pwc e: 713 zr <br /> Reporting Agency Name: o�C v.✓ e <br /> Address: n/a r' c Com` 91ER0 <br /> C. LOCATION AND DYE=FD CHARG <br /> Location: /!F <br /> (Best Physical Description) ! Ci r County) Circle One <br /> Date of Discharge: 4oc,�P7 � I <br /> Date Notified: '/ Time: Ci it <br /> D. RESPONSIBLE PERSON/BUSINESS �I <br /> Name of Business. 4 :n C�.r <br /> Contact Person:- Telephone: ? <br /> Physical Address: O f <br /> Mailing Address: -.4 .I <br /> E. DESCRIPTION <br /> Type of Disch ge: u <br /> Volume: Uts ffof ownII II <br /> Chemicais: <br /> Circ otances: t2;, o �� C ✓era <br /> s� <br /> F. ACT NT N i 1i1 <br /> 'If II <br /> II �� <br /> f G <br /> f� II <br /> SIT ISPOSITION <br /> 1,4 e_X1647L IeDtl Z62wf42 <br /> iE <br /> II it <br /> I <br /> EH 22 013 (Rev.4/91) <br />