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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 C (0 MED Y <br /> LF <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # .—z�1 <br /> Ircle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: L� <br /> Company: <br /> Address: <br /> Designated Employee Name: ✓'vtPh,,Qne: <br /> Reporting Agency Name:- vt C6, �b Z, �/r-. f�+\6/kDyi. i <br /> Address: Cwt—q <br /> C. LOCATION AND DATA OF DISCHARGE <br /> Location: ��`� V��JJ GKt.K4e r / S <br /> (Best Physical De cription) J&jbr County) Circle One <br /> Date of Discharge: v <br /> Date Notified: -7 q S Time: I l`�:OZ <br /> D. RESPONSIBLE PERSO �/BUSINES� <br /> Name of Business: ( � ,�5 EES- L- {-- <br /> Contact Person: cY fS Telephone: 9</7, 10 <br /> Physical Address: t 3-;L( S L'n c. <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: t 2 6{ <br /> Volume: <br /> Chemicals: <br /> Circumstances: Ne- cSYt vn r r�cz E c� S c�13 C�✓���� ��,lam <br /> c�+- G� IMan 7 v� r6� y-)e,LI Keds W rv2 r <br /> cs� Z viwxr�3 l6Lg3 <br /> F. ACTION TAKEN Q�Y �' 5 -ie� a� GuCr"LI awf�- LEX a/' ly <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.4/91) <br />