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SAN JOAQULN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE C <br /> O o <br /> HEALTH &c SAFETY CODE 25130.7 <br /> A. EMERGENCY LEVE(- ,C,i)rcle <br /> II III PHS-EH LOG Y O3 <br /> one) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: A6Z�`7 <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name:G✓.� tY L'�C �.4 ' J ik c7a V <br /> Address:2)L4L43 rz_ou,� Q.,^ <br /> C. LOCATION AND DATE OF DISCHARGE <br /> f <br /> Location: <br /> (Best Phvsical Description) (CitV'or CountV_ ) Circle one <br /> Date of Discharge: <br /> Date Notified: ( cf'j Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Phon :b(y f S,;Z� - Oc7a <br /> Physical Address: (r ;z 6 04 30(_7 <br /> Mailing Address: 2J Du(!�2 3a 1� <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: LA V\_ <br /> Chemicals: <br /> Circumstances: ,lti tu+� yt G w-f3 i 5� ��e�t'Ec 1 it �a 4 �Y- SG o►�Q 12ss SIG r� <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> �V'2 W V'� a v, Iy,�3 {+ q atter �l � ✓� c,c oayt�-ty1 GL,--J <br /> J <br /> EH 22 01:, (Rev. 08/20/98) <br />