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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISC GE --: <br /> HEALTH & SAFETY CODE 25186.7 ! <br /> I <br /> A. EMERGENCY LEVEL: I II III <br /> PHS-!EH LOG # <br /> ( ircle One) F. a <br /> B. SOURC F INFO T O i 4_Zl� <br /> Name: u Phone: <br /> Comp an Kf <br /> Address 7 �_ <br /> Designated Employee Name: 9E i' Phone: C--,J <br /> Reporting Agency Name: <br /> Address: . .:,ij <br /> C. LOCATION AND DATE OF DLSCHARGE <br /> Location: /2"lD / �✓'�,: / <br /> (Best Physical Dec • tion) . I a Cary r County) Circle One <br /> Date of Discharge: - <br /> Date Notified: - — Time: do <br /> LO O a <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> /yam i, <br /> Contact Person: ! Telephone: <br /> Physical Address: <br /> f <br /> Mailing Address: <br /> 4 f� <br /> Cs. <br /> E. DESCRIPTION ' <br /> Type of Discharge: <br /> Volume: e)N <br /> Chemicals: 1U <br /> Circumstances: <br /> F. ACTION TAKEN,- <br /> eFe lb <br /> eJu1 ire. <br /> f. <br /> SITE STATUS <br /> S <br /> EH 22 013 (Rev-4/91) <br />