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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: 0 if III C O PYPHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: AAZi�j Phone: /5 <br /> Company <br /> Address: 3Sa,J - (-� ZY '� doe)_ <br /> Designated Employee Name: Phone: (� <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: -77-5� �— <br /> (Best Physical Description) (City r County) Circle One <br /> Date of Discharge: . u ,KNOWN <br /> Date Notified: ` 3'Y2_ Time: _ e13Oo <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: 164- 114e &Z_1 Telephone: <br /> Physical Address: <br /> Mailing Address: /'70 9 SO <br /> E. DESCRIPTION <br /> Type of Discharge: U X1vaw1y sou ece <br /> Volume: cv/c% <br /> Chemicals: <br /> Circumstances: , Q <br /> F. ACTION TAKEN .3 <br /> SITE DISPOSITION <br /> 3 <br /> iLa G G/ .co <br /> EH 22 013 (Rev-4/91) <br />