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tawSAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL.0a III PHS-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: 5�' ,:noe - 1-{ Phone: CaaY2 y6 <br /> Reporting Agency Name: c-n .`,rocs.,4-1 Co. -P�`,5 - F-�vc <br /> Address: y'-/5 4l <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: -5. 4,y ql / .1 64 <br /> (Best Physical Description) ', (City or County) Circle One <br /> Date of Discharge: <br /> Date Notified: 5'— z s - s z Time: 3-leo .� . <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: C- <br /> Contact Person: Telephone: z©1 sgs- -rwi z <br /> Physical Address: z=-r i z iliP-1.a o <br /> � � 1 <br /> Mang Address: _�► ���-� o l Cc,. z v M ' �„et C";. S. <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: s e / <br /> Circumstances: --7� <br /> F. ACTION TAKEN_/�•ir/.ic G .�v •rc do SDRC iia '�- �a i <br /> � i� r s G%/ 7�jo r /f�G v++ o✓ � <br /> --fes.��.rt ii to �14/Yro .i/cg %S7`.;t- <br /> -4)+d <br /> i <br /> SI'i'�' DISPOSITION �-- <br /> EH 22 013 (Rev.4/91) <br />