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SAN JOAQUIN COUNTY .r <br /> NOTIFICATION &IIONHAZASAFERDOUS <br /> CDE�80.DISCHARGE CHARGE <br /> PHS-EH LOG # <br /> A. EMERGENCY LEVELC11 cle l se) <br /> B. SOURCE OF INFORMATIO 3 y2-)- <br /> Name: I�QVL r uJC Phone: E — <br /> Company: oY iCl x n w am fa �I S� 3 <br /> Address: );rt <br /> Phone Q ) T �`�` a <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION ANDDDODATE QF DShCHARGE / 4C=Location: <br /> �v C ) Circle One <br /> (Best Physical Descriptio <br /> Date of Discharge: Uor--OOZuh <br /> Time: <br /> Date Notified: 60 L4121 <br /> q Gb 'trv� <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: id0 CorTelephone: <br /> Contact Person: P <br /> Physical Address !n S U11 r E t±, L've u /-e.. <br /> �- ' l�-l'�c1/IYtLr.trD ZJ <br /> Mailing Address: 6a'rnQ- <br /> E. DESCRIPTION <br /> Type of Discharge: ed <br /> Volume: <br /> Chemicals: Wi- <br /> Circumstances: <br /> F. ACTION TAKEN :�Ln X/w <br /> SITE DISPOSITION U5"T trlr1-0,,w Una �n IV _ et1d eze,777,n� ,y /Y1 <br /> EH 22 013 (Rev.4/91) <br />