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SAN JOAQUIN COUNTY <br /> NOTIFV- TION7OF HAZARDOUS WASTE DIHARGE x <br /> HEALTH.& SAFETY CODE 25180.7 'k <br /> A. EMERGENCY LEVEL:�II IIt PHS-EH LOG #(0 <br /> S <br /> (Circle One <br /> B. SOURCE OF INFORMATION <br /> Name:— -57 Phone: (20 7 0 <br /> Company: 6/4 <br /> Address: <br /> Designated Employee Name; Phone: f. <br /> Reporting Agency Name: <br /> Address: <br /> y <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: /rz v Lie i= cky4r � <br /> (Best Physical Description) City r County) Circle One <br /> Date of Discharge: 1Nk ,: 4 <br /> Date Notified: _._. 7- /G ..F/ <br /> Time: : <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> '; Name of Bushiess: <br /> Contact Person: Telephone: ( F <br /> Physical Address: Al2-/0 (5- <br /> Mailing Address: S <br /> i <br /> E. <br /> DESCRIPTION 4 ' <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: 4 #: t ,: .. jo <br /> Circumstances: G <br /> - <br /> `i F. ACTION TAKEN <br /> CB <br /> SITE DISPOSITION <br /> F _ <br /> EF-i 22 013 (Rev.4/91) <br />