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SAN JOAQUIN COUNTY <br /> NOTIMATION OF HAZARDOUS WASTE D HARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL*4111 III 6\, P-7— <br /> PHS-EH LOG # . <br /> 1 L e One) <br /> F <br /> B. SOURCE 0 INF¢ TION <br /> Name: 'M Phone: <br /> Company: C �[ <br /> Address: BlvdA 9i zl <br /> Designated Employee Name: adj2Phone: ( 3 <br /> I; <br /> Reporting Agency Name: 3i <br /> Address: <br /> C. LOCATION AND DA7 OF DISCHARGE <br /> i Location: &Z <br /> (Best Physical Description) Ci r County) Circle One <br /> Date of Discharge: l� <br /> Date Notified: S7!8 Z Time: :STD <br /> e <br /> D. RESPONSIBLE PERSON BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: <br /> Physical Address: Z a1L ` ZO <br /> Mailing Address: �4 alkv-, � <br /> E. DESCRIPTION h <br /> Type of Discharger �rnm UJ l <br /> Volume: L&i l 1,GfZ61,u)i <br /> Chemicals: r <br /> Circumstan es: PvJ Y - <br /> F. ACTION TAKEN <br /> s <br /> k <br /> SITE DISPOSITI. N W AJJM i <br /> Y f < ' <br /> 6 <br /> f. <br /> H <br /> EH 22 013 (Rev.4/91) <br />