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�� -- SAN JOAQUIN COUNTY <br /> NOTIFICA ]N OF HAZARDOUS WASTE DIS&*ARGE <br /> HEALTH & SAFETY CODE 25180.7 C(D T� 7y <br /> A. EMERGENCY LEVEL: I .i1 RI PHS-EH LOG # <br /> ( cIe One) <br /> B. SOURCE OF INFORMATION <br /> Name;_ ^.SD`i s��t �r' �/ �•� Lii/�zDda� Phone: <br /> Company: <br /> Address: 77 <br /> Designated Employee Naze - Phone: - <br /> Reporting Agency Name: Ie�En1 r` ti,v , l'i Oe azvleit,E! <br /> Address: O . 6Q-4 <br /> C. LOCATION AND DATE OF DISC`HIARG <br /> Location• „(itJ, <br /> (Best Physical Description) (City or Count. j Count. Circle One <br /> Date of Discharge: <br /> Date Notified: Time: ;6)C -,... <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: • - - i Telephone: <br /> Physical Address: c <br /> Mailing Address: <br /> E. DESCRIPTION �I <br /> Type of Discharge: , <br /> Volume: <br /> Utj V-4,92 W <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN <br /> ZI Ile-- G e- <br /> S7E DISPOSITION <br /> 5. <br /> 1 <br /> +1 <br /> EH 22 013 (Rev.4/91) <br />