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# SAN JOAQUIN COUNIY U <br /> NOTIFICATION OF HAZARDOUS WAS i c D[SCH A RGE <br /> i HELI.i H & SAFETY CODE 25x80-7 <br /> A- EMERGENCY LEVYc.I.,: I If III P,HS-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFORMATION i <br /> Name: Phone: ] IV6-7 - <br />'I Company- ' / <br />� 'd :id m4c <br /> Address: <br /> Designated Employee Name: Y' i,- Phone: <br /> Reporting Agency Name: <br /> Address: ;P <br /> C_ LOCATION AND DATE OF DISC:-LkRGE p <br /> Location:� 1 3a3 �'LZ�n� <br /> (Best Physical Descripdon) (City o<0Luu Circle One <br /> Date or Disc-barge: <br /> Date Notined: "" <br /> Time: <br /> D. RESPONSIBLE PERSON/BU_ SD/ESS <br /> Name of Business: r C1t'1 G7�G �• <br /> Contact Person: ` G�Ct�c Telephone: ~' <br /> Physical Address: G' <br /> mailing Address: S - <br /> .I <br /> E. DESC'RPTION - <br /> Type oC Dis&.arge: _ u A <br /> Volume: <br /> C4eT dcals: <br /> Circumstances: <br /> ' W CLD L2r(, <br /> ACTION TAKEN <br /> + `R <br /> A r IL <br /> :k <br /> ITE STATUS <br /> dk'aJ r+/ <br /> f <br /> fi <br /> if <br /> 'k <br /> 'F <br /> EIH 22 013 (Re.1.4/91) <br />