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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL I SII III PHS-EH LOG <br /> cle One) <br /> B. SOURCE OF INFORMATION '5/t, �`� _ 3/ <br /> Name: S: c�k-cP �_� Phone: (!) <br /> Company: <br /> Address: <br /> Designated Employee Name: w ReS Phone: )' / ?'3 <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> a <br /> Location: ) L, (}'LJ / G C, <br /> (Best Physical Description (City o Coun Circle One <br /> Date of Discharge: / ("�3' y/ <br /> Date Notified: j S-- / L, 'q 1 _ Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: 4Lf Telephone: <br /> Physical Address: -3 f <� 1 c ' S C13 ` 7C 1 <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: -4-- / — / y— CSF <br /> Chemicals: =� A <br /> Circumstances: <br /> _ L /�F. ACTION TAKEN <br /> SITE DISPOSITION d c 6- G&? <br /> 121 <br /> EH 22 013 (Rev.4/91) <br />