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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISLHARGE <br /> HEALTH & SAFETY CODE 25180 . 7 <br /> A. EMERGENCY LEVEL : 6) If III C (0 PHSwEH LOG # /�7r>C <br /> (Circle One) <br /> Be SOURCE OF INFORMATION <br /> Name : ,C�-G �taac�Go�` oI u/am Ld Phone: (�) <br /> Company: _ C� u�-�-�— <br /> Address : el/ 9/ Gogo dLd,�5a 9SFayo <br /> Designated Employee Name : Phone: �) <br /> Reporting Agency Name : <br /> Address : <br /> C . LOCATION AND DATE OF DISCHARGE <br /> Location: �oG /04 / <br /> (Best Physical Description) City or County) Circle One <br /> Date of Discharge : �G� <br /> Date Notified : 3 • �( -9z Time : P� — <br /> D. RESPONSIBLE PERSONBUSINEs S <br /> Name of Business : ce t,,� <br /> Contact Person: _ —� Telephone : <br /> Physical Address : .1000 Q2%% 1 IGam • <br /> Mailing Address : le�' 0. /JoX S�!.a � 279l Ke <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> volume : <br /> Chemicals : <br /> Circumstances :zcoeo <br /> itaau <br /> F. ACTION TAKENer <br /> Oa �Cer` /L�a-� •( ( �4i Q /� /lpz <br /> SITE DISPOSITION .0,Zc <br /> EH 22 013 (Rev.4/91 ) <br />