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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.70 <br /> it 3 <br /> A. EMERGENCY LEVEL: I ' ll III PHS-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: V Phone: + <br /> Company: <br /> Address: 6 Y Lf iv wV S a� C ii q <br /> Designated Employee Name: .✓A v Ph rie: <br /> Reporting Agency Name:_j <br /> Address: 6 a 20 o G - <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: I 6 S 5 [.-�� c v L M <,>7- <br /> (Best <br /> r(Best Physical Description) (City;or Coon Circle One <br /> Date of Discharge: U N k tA o z.•1 n.1 <br /> Date Notified: — 1-3 -,�,� Time: ;o o <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: A 11F _S c,� ssal I crew7 <br /> Contact Person: 22 Telephone: v <br /> Physical Address: 1 6. r <br /> Mailing Address• .S.g-m e-- A-s A-6,,V e <br /> E. DESCRIPTION <br /> Type of Discharge: A V <br /> volume: <br /> Chemicals: M o f L <br /> Circumstances; ert A-01 Ca- o 2 ' 1C l <br /> i' e- o <br /> F. ACTION TAKEN <br /> U V` <br /> i' <br /> !3 Ile <br /> 5 DISPOSITI N FLA 1Z:H,.e M <br /> .� FI. u i <br /> tCLeg <br /> !; <br /> I <br /> EH 22 013 (Rev.4/91) <br />