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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I [IMIPHS-EH LOG #-1), <br /> (Circle e) <br /> B. SOURCE OF INFORMATION OO <br /> Name: x19 a Phone: Zaf <br /> Company: ice;-���;s G• b <br /> Address: 4z 3&,) dV< h''o � a f'3 57 <br /> Designated Employee Name: o f/' Phone: (�) 1,16 4'm 3 3 r <br /> Reporting Agency Name: <br /> Address: yy <br /> C. LOCATION AND DATE OF DISCHARGE - <br /> Location: <br /> (Best Physical Description) r County) Circle One <br /> Date of Discharge: ✓� //Oa✓A <br /> Date Notified: 2 - Z 7- S Z Time: 7 3o <br /> D. RESPONSIBLE PERSON/BUSINESS. / <br /> Name of Business: -- <br /> Contact Person: ,zc�,i -Telephone: <br /> Physical Address: zx i �(/ n2�-- ►"i n i-e�s . c4 s 53 3 <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: �w <br /> Chemicals: — vf/1,'10 <br /> -� / �' •'- ,:� <br /> Circumstances: in' <br /> F. ACTION TARN_ <br /> 42 <br /> SITE DISPOSITION s <br /> ' <br /> EH 22 013 (Rev.4/91) `-� <br />