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:5:SaYm F Kum <br /> Y L <br /> SAN JOAQUIN COUNTY `'� Qr s f <br /> r1 � <br /> t� I <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE ¢ <br /> HEALTH & SAFETY CODE 25180.7 9 <br /> A. EMERGENCY LEVEL:(DI III PHS-EH LOG # �— J <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (� <br /> Company: 5 F ��r orGF <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting A�,ency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCWGE q Z?,5DUS <br /> Location: rvZG <br /> (Best Physicalescriptio (City o i ) Circle One <br /> Date of Discharge: a4w rt , <br /> Date Notified: `rte/rVTime: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: E Telephpne: (� <br /> Physical Address: 9Zo 47-,Gve2�z- /a v,<'T2z 3 z-(Z <br /> Mailing Address: - - <br /> E. DESCRIPTION <br /> Type of Disch ge: e- <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKENrcgG <br /> uP413 243 <br /> DrS svgs cYa � �a. r i.G��-r' <br /> SITE DISPOSITION r- <br /> o <br /> ear/" "r- <br /> EH <br /> __.. <br /> �d dGca-�f�rl G� <br /> EH 22 013 (Rev.4/91) <br />