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SAN JOAQUIN COUNTY s <br /> NOTIFICATION OF HAZARDOUS WASTE DIS(MGE <br /> HEALTIH & SAFE 1 Y CODE 25180.7 <br /> A. EMERGENCY LEVEL:On III � PHS-EH LOG � �� ��G <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (� <br /> Company: <br /> Address: <br /> Designated Employee Name: 5�' ,:nor - 1-!: Phone: -zit Y, <br /> Reporting Agency Name: Stn `moa��,-� <:.. •Pr5 - ��-d <br /> Address: Y'-1Is 4 1 . .5S•^_ <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: Z z7 Z Z S. 1'741V �� / •�Do� <br /> (Best Physical Description) (City or County) Circle One <br /> Date of Discharge: <br /> Date Notified: 9 - s Z Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: �� r T(J G`C z_4 <br /> Contact Person: 0. Ae CA Telephone: <br /> Physical Address: z=-r z z S - �k,, e 9 R;..6 o <br /> Mailing Address: o 1 O,l C.. Z o U C4• C-1 <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume:Chemicals: - <br /> Circumstances: <br /> F. ACTION TAKEN C 4a 117 '1,- iia s <br /> SITE, DISPOSrITION <br /> .,-,++��;� �n r�ro..� �i���/ /illit�s�loc •'on Li,•/� �� <br /> n�•� �cci/ �v /P�!irrl.��c �� ex�-+•�r .oil 1"�c <br /> EH 22 013 (Rev.4/91) <br />