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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE } <br /> HEALTH & SAFETY CODE 25180.7 <br /> l <br /> A. EMERGENCY LEVEL Ii IIi PHS-EH LOG # -� <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: G Z `.-j V,%-w h n <br /> ,r.j Z"IA ell Phone: (2vs <br /> Company: u-•-e A s .r.; <br /> Address: ,)SDQ S2 a& oG / ,ems! <br /> Designated EmployeeName- Oar,al '- Phone: ,V- Y&5' -3 2 y o l <br /> Reporting Agency Name: aS' � ' E <br /> Address: s' ,:� c'E '' `9 <br /> C. LOCATION AND DATE OF DISCHARGE l <br /> Location: p y i/ F, -, -- >.V,,� <br /> (fest Physical Description) �ty County) Circle One <br /> Date of Discharge: ew-v7 <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: .4 F - <br /> Contact Person: eG Telephone: <br /> Physical Address: q.• _ n�r-�' s�� i` H <br /> Mailing Address: o Cr-5111-is- <br /> E. <br /> 11-irE. DESCRIPTION - <br /> Type of Discharge: ewta e,e4 f!ivr r-- <br /> Volume: _ G•h�� � .�,� <br /> Chemicals: Al T" <br /> Circumstances: 1Vo4c <br /> F. ACTION TAKEN ,,(- <br /> SITE <br /> kSITE DISPOSITION sic s l/ de- -es-s �•- <br /> EH 22 013 (Rev.4/9I) <br />