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�40V <br /> SAN JOAQUIN COUNTY o `� <br /> NOTIFICATION OF HAZARDOUS DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: & R M PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: t g6 a Gc M 0 P tJ Phone: <br /> Company: G t•s%' R.o,4 <br /> Address: tl 0 E LA-g5 2u 5 c&' <br /> Designated Employee Name: W �-�-�, -- tZ. St., A-v s1',, Phone: S/6d 'fZo <br /> Reporting Agency Name: Spiv ^�-- ;, w Pry b l t, ',N-�A LMt �.zy �e6s- <br /> Address: OOF <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 3 -fL�Y' oGOgg-pA, H'�L-t.o 12r� / •T� - f � .3"7� <br /> (Best Physical Description) (City or County) Circle One <br /> Date of Discharge: yrJ K vw w r4 <br /> Date Notified: M-3—I& Tune: <br /> D. RESPONSIBLE PERSON/BUSINESS S p•� <br /> Name of Business: <br /> Contact Person: Telephone: W. <br /> Physical Address: S jr a CoAA& G w CA; 1 <br /> Mailing Address-., C �Y <br /> iso R-G-A-nJ r V(. � G.,4 cT S'Z7 3'7 s <br /> E. DESCRIPTION <br /> Type of Discharge: ,k i �►-� <br /> Volume: K. <br /> Chemicals: w1 S <br /> Circumstances: . <br /> F. ACTION TAKEN �-���'�-c-�- <br /> -L�v Al <br /> A a.R-w��"r -t"o r►-�,�e K -{mss- !-1� C g SSArre-N <br /> I,/N f- h4e AA R. i F <br /> SITE DISPOSITION S <br /> r <br /> - o <br /> h o •1 <br /> EH 22 013 (Rev-4/91) <br />