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SAN JOAQUIN COUNTY :r f <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> i <br /> A. EMERGENCY LEVEL: I III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: fnA %rcgL Phone: - <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address:_ E_ *,gffo, at-F.C. LOCATION AND DATE OF DISCARG <br /> Location: ;3c, <br /> 1 <br /> (Best Physical <br /> ptia�} County) Circle One <br /> Date of Discharge: A5 vwn <br /> Date Notified: _ 1f,A3� Time: ra= <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person:' r�' Telephone: Gnc-7) - <br /> Physical Address: 33c, GOa o <br />�- Mailing Address: Wo <br /> E. DESCRIPTION <br /> Type of Discharge: v Zc r 4 <br /> Volume: <br /> Chemicals- . <br /> C.Lr 'StaIlces: ? k. L2-- oti T <br /> F. ACTION TAKEN U 5. 7-- �S � � •� yE.o a,�I ��f�z/��'. - <br /> r <br /> SITE DISPOSITION <br /> f <br /> 4 <br /> i I <br /> EH 22 013 (Rev-4/91) <br />