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i <br /> '*) SAN JOAQUIN COUNTY <br /> j NOTIFICATION OF HAZARDOUS WASTE DISCHARGECO <br /> HEALTH & SAFETY CODE 25180.7 {J <br /> i <br /> I <br /> A. EMERGENCY LEVEL:0 II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> 1. Name: Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: _gea,4 �Ijyq4,1d4 lyyyl at- <br /> Address:-30 ,41 AM,�— .mr� , rer 4.r?zZ, <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: Z70/ A/_ <br /> (Best Physical Description) Caty r County) Circle One <br /> Date of Discharge: ( v<u-v AJ w7 . <br /> Date Notified: Time: A4 , <br /> D. RESPONSIBLE PERSON USINES 6 <br /> Name of Business <br /> Contact Person: Telephone: .fS/o) Z77-Z-3,/ <br /> Physical Address: oo - 3 <br /> Mailing Address: 02 0. Z3 9 0 fS ��a , ca 9 z s u-Z 33 7 <br /> E. DESCRIPTION <br /> Type of Dischaz a— <br /> Volume n <br /> Chemicals -eA <br /> Circumstances: <br /> F. ACTION TAKEN h0_24A_ •_ S�`� �n c�� 2w�'. <br /> J <br /> SITE DISPOSITION <br /> a 400 02c, <br /> i <br /> - <br /> EH 22 013 (Rev.4/91) <br />