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I , � <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH <br /> � �& JS�AFETY CODE 25180. 7 <br /> � Z PY <br /> A. EMERGENCY LEVEL : (I )II III FHS-EH LOG <br /> (Circle One) <br /> I <br /> B . SOU <br /> RCFOF INFORM TION <br /> Name : Phone : ( /), G ) <br /> Company: _� C / c s e r�t < <. <br /> Address : 9/ �$ , 95� <br /> Designated Employee Name : Phone : (� <br /> Reporting Agency Name : <br /> Address : <br /> C. LOCATION AND DATE OF DISCH RGE <br /> Location : �i l0 /V <br /> IO . ee za-tad6 / S�jck?ze� <br /> (Best Physical Description) tty r County) Circle One <br /> Date of Discharger <br /> Date Notified : S-9/ Time :. �3to <br /> D . RESPONSIBLE PERSONESSp / �� <br /> Name of Business : f..4O�ee�Ge <br /> Contact Person : t Ca.v..�a L ff Tel hone : (� $ �/ � 5�3 <br /> Physical Address : ? 000 / z . , ,le f de ac ��( , , �; -� � r i�:� c.r? <br /> Mailing Address : VD. — b - 56;P/ / <br /> E . DESCRIPTION <br /> Type of Discharge : <br /> Volume : r/.tJK _ <br /> Chemicals 57i��AVe <br /> ._YEW <br /> Circumstances : <br /> F. ACTION TAKENa�_� ° ' �¢ . <br /> SITE DISPOSITIO <br /> amu/ - <br /> mp <br /> i <br /> A.Ar.�S J co <br /> ---.---� <br /> EH 22 013 ( Rev. 4/91 ) <br />