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12-od-1v`b 10:29AM FRI IN TO 9449015 P.02 <br /> S331AHIS A5N35t,. <br /> SAN JOAQUIN COUNTY AW03 WiC,.- <br /> NOTIFICATION OF HAZARDOUS WASTE DIS GE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I [I III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (�) <br /> Company:_ <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address:! <br /> C. LOCATION AND DATE OF DISCHARGE l <br /> Locations 1s < r rr^o j facAJ <br /> (Best Physical Description) (City r County) Circle One <br /> Date of Discharge: <br /> Date Notified: Time:o,dzj <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: _ 41 S. _ <br /> Contact Person: /f/ S. K Telephone: <br /> Physical Address: (kb 11IIF �� •-- 5a <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: C a.,,.rt Ll <br /> Volume: i U ,17c <br /> Chemicals: �d <br /> Circumstances:_ �( c. �.,�.iGLils�✓ <br /> F. ACTION (TAKEN ("�-ei ; alef T I�<s ..,aa )na V�n,e <br /> i <br /> I <br /> SITE DISPOSITION Nw,,t o ci tar 4=Lu- Tn 1- ni 1Aw <br /> i <br /> i <br /> EH 22 013 (Rev14/91) <br /> - I <br /> I <br /> DEC-28-1995 09:55 <br /> 9 ?. P. <br /> I <br /> cc: / (� ( ( ,,,,, t, ) SWEEPS#/SITE CODE#: <br /> CONMFR Y/ N <br /> �-{ \ REFERRED TO: <br /> EH 22 013 (Rev.4/91) <br /> TOTAL P.03 <br /> DEC-28-1995 09:55 93'r, P.03 <br />