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`.r SAN JOAQU1N COUNTY 1-w� ILE <br /> COPY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCELARG <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVELIII III PHS-EH LOG T • d(p� <br /> ((7ircle one) <br /> B. SOURCE OF 1NFORN- L-.TION <br /> Name: Phone: ( ) <br /> Company: <br /> Address: SS l C11 AJA /3, Sa-Gla.,"-e,A. 2 9 SFl.lN. <br /> Designated Employee dame: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCH_A.RGE <br /> Location: -Sf <br /> t--• <br /> (Best Physical Descri ion) City or County) Circle one <br /> Date of Discharge: <br /> Date Notified: O U Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> dame of Business: <br /> Contact Person: D1cjz- 16�1/- Phone: <br /> Physical address: <br /> Mailing Address: a� <br /> E. DESCRIPTION <br /> Type of Discharge: A Cl[A A-l (s1 rz PG <br /> Volume: (nom&k <br /> Chemicals: c, <br /> circumstances: <br /> F. ACTION TAKEN 0� 1&434 &&1Ad-'-L4 eX <br /> P} tiAvr►%ncO Pn�wYb►�.Nn�ti .�� odSSSeSS <br /> SITE_ DISPOSITION Si At-) Ss-,— v2,CrAr., Q AAA LC P�y� <br /> V ' <br /> EH 22 013 (Rev. 03/20/93) <br />