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�,W SAN J©AQUIN COUNTYD�OE <br /> NOTIFICATION OF HAZARDOUS WASM <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY Lvmjo Q M PHS-EH LOG � <br /> (Mcle One) <br /> B. SOURCE OF INFORI4lATION3 <br /> S51i 3 !.3 <br /> Name: R-bryt K e r rt.5 Phone: �) - <br /> o <br /> Address: +-( I n 2eL •-"r-OL <br /> Desigmed Employee Name: Ph=: <br /> Reporting Agency Nance: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> LAcati,on: <br /> pb�cil Descxi (City orx0=qp=M One <br /> Date of Discharge: ''"- <br /> Date Notified: 4=37 wo e <br /> D. RESPONSIBLE PEIBUSSS <br /> Name of Business: r 3 <br /> Co 9*a Person: Td e• 11,Phydal 331 <br /> Address: I ne_ <br /> Mailing Ada. <br /> E. DESCRIPTION <br /> Type of Discharge: c` -0— <br /> Volume: <br /> Chemicals: <br /> Mee <br /> Citcumst�ances: en <br /> { Ga <br /> F. ACTION <br /> ISI rrl a u.r..rrY <br /> I --— I �YI.YY..I IYnP_III <br /> SITE DISPOSITION n <br /> Ice <br /> EH 22 013 (Rev-4/91) <br />