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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 , 415- <br /> A. <br /> SA. EMERGENCY LEVEL: I II III PHS-EH LOG n 03 - 0�3 <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Name: John 1 k otn Phone: (Zq (-16f3-3 CII <br /> Company: �� �bn u i cn j I',, m e✓i 14ecx l ,k DeRi f+ WteVI-I- <br /> Address: 3030 6 C� bet AuP S4or'k+eh Co 95Z67 <br /> Designated Employee Name: Scvme Phone: -o9 V68- 3r/y6 <br /> Reporting Agency Name: 5cwn e <br /> Address: 5,-we <br /> C. LOCATIONN AND DATE OF <br /> OF DISCHARGE pFwY ws By <br /> Location: / te�c0 !Jn The A)�� it rrl <br /> (Best Physical Description) / (Ci or County) Circle one <br /> Date of Discharge: A�reC �Ix2r �/ 700 <br /> Date Notified: // Time: '/0:S'0 A," <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: 5 {a¢or� G sriFe Jr Pon : 835- Z 7a/ <br /> Physical Address: ZZ S 77 IM000lift" fleule tj y <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: ^ 3, 000 12a E 15 /?6! 00 , er0 <br /> Chemicals: aJ <br /> Circumstances / �i 1/e rel r l B C1-,Adz o <br /> F. ACTION TAKEN <br /> En Ji�n rNfl+2�� o c n�v1 <br /> e-leoo <br /> SITE DISPOSITION 5, 000 <br /> I <br /> //�C 4 2d � //I•� q. I IA� � <br /> EH 22 013 (Rev.08/20/98) <br />