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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180. 7 <br /> A. EMERGENCY LEVEL: I) II III PHS-EH LOG # U � 3 <br /> (cir( le One) <br /> Be SOURCE OF INFORMATION <br /> Name : i ` i.i hi Zvi c Phone: 3( (b , °fol - i> � �/ <br /> Company: C (J S <br /> Address : `� F� .t , �� , <i . _ < a <br /> Designated Employee Name : L .-(-i � ' C� C Phone : fes) qL o - 3 y J <br /> Reporting Agency Name : <br /> Address : <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location <br /> (Best Physical Description) (City or County) Circle One <br /> Date of Discharge : &k - l _c/ <br /> Date Notified : ! / 3 y� Time: <br /> D . RESPONSIBLE PERSON/BUSINESS //! I ��> �� 0 � `� <br /> Name of Business : b11/ IIJ Fo o G� � s � �� a d 5 ` o <br /> Contact Person: 5 G2� • � ;r ,`' / TeI hone : � <br /> Physical Address : IC <br /> Mailing Address : tom n ( 5` / a� e-� i C 4 q 2 ::> 76 <br /> E. DESCRIPTION <br /> Type of Discharge : <br /> volume: <br /> Chemicals : 9 a 4rz,4, �-'� <br /> Circumstances : /7 u � n1c '. B t frt Uw �T <br /> F. ACTION TAKEN <br /> P r i c -< <br /> SITE DISPOSITION _.� ! - rn_. i DycJ 77 , <br /> EH 22 013 (Rev.4/91 ) <br />