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%ftwe SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARG Py <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:0II III PHS-EH LOG # ? 5 ^ P/ 7 <br /> (Circle One) <br /> B. SOURCE OF INFORMATI0 <br /> Name: Phone: <br /> Company: �j- cQ <br /> Address: <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address: �• c�,'a-5,1-e .9rF- s r,4 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical es 'ptio ) mor County) Circle One <br /> Date of Discharge: <br /> Date Notified: , Time: : oo <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: --T`,e,Gs 11 .1 n <br /> Contact Person: Telephone: z- air e-,5- <br /> Physical Address: 900 <br /> Mailing Address: ` o tz7rs <br /> -- — <br /> E. DESCRIPTION ff <br /> Type of Disch ge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN <br /> r avcr .4s ,e�r'isE.4.o <br /> SITE DISPOSITIO r r s.r� ss6s r- rte. <br /> 14 <br /> EH 22 013 (Rev.4/91) <br />