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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> FILE COPY ' <br /> 4 <br /> A. EMERGENCY LEVEL;("[) II III ' PHS-EH LOG # O Q3 <br /> (C'lircle One) <br /> B. SOURCE OF INFORMATION ' <br /> Name: War Phone: (_) I <br /> Company: <br /> Address: 'a 7 1 y I <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: ` <br /> Address: <br /> C. ' LOCATION AND DATE OF DIS,CHARGE <br /> Location: 4 l�? Lk) IVG�- � <br /> (Best Physical Description) ��or County) Circle One <br /> Date of Discharge: I,�M 1 a Uj r1 <br /> Date Notified: 'F 1 a-41 a Time: 1 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: C-� f <br /> Contact Person: Safe Telephoner zS 9 1 2-- 9XI,,1 <br /> Physical Address: ._ <br /> Mailing Address: 6 4 Y14 a' , L/ S <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> volume: _ f A vi r� <br /> Chemicals:^ r n <br /> Circumstances: P e d 50( 1 -$e,nl% S j n r - <br /> F. ACTION TAKEN._. r�r?rn�S1 e <br /> SITE DISPOSITION <br /> !f <br /> EH 22 013 (Rev.4/91) = �` <br />