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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:. II III PHS-EH LOG # <br /> (Circle!One) <br /> B. SOURCE OF INFORMATION <br /> Name:_ t/ ,G z�j Phone: S5 - ?C y <br /> Company: S AYR C ; <br /> Address: to r F•X'-e C LA'v`e_ �-t�� <br /> Designated Employee Name: U,-F i-,' 13r j�f� Phone: ( !j�Z,f?-3 `41, <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF 'DISCHARGE// <br /> Location: Cl:3�, 1' .24' 126LX / �S <br /> (Best Physical Description) (City r County) Circle One <br /> Date of Discharge: <br /> Date Notified: G� —,1 �'' l7 Time: _ - 17``06�ry�, � <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: v <br /> Contact Person: Telephone: (� <br /> Physical Address: s iE-e- L; tL c, <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances:C24-7)A 12 - <br /> �. <br /> tc P.rnc� 7 <br /> 1-3 <br /> F. AC=N TAKEN <br /> SITE STATUS <br /> CU r:»��.tgs lG /r1N—f�� <br /> -H 22 013 (Rev.4/91) <br />