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r 1 , SAN JOAQUIN COUNTY U -1 <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 1` fk11 1{ <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # q <br /> (Circle One) ' <br /> B. SOURCE OF INFORMATION .,r• ', ` ' 'I r� ` <br /> Name:. S %rt—S '' Phone: (Rt b) 'i8z-21tD <br /> Company:. PsyS(a1? 01%4 ty&coi 1 <br /> Address: LSi��rl� U'Aj <br /> Designated Em to eb Name Phone: <br /> Reportting Agency Name: <br /> Address,— <br /> ,. P,; • ;• . r <br /> C. LOCATION AND DATE OF DISC GE '� "" � ` } <br /> Location: / I <br /> (Best Physical Description) '' " City r Covrity) Circle One <br /> Date of Dischatge: .: ,,x,.; ..: -- <br /> 1�i�1ea�� . i <br /> Date Notified: 9 -30 --iI Time: 100 o,nn r <br /> D. RESPONSIBLE PER96N/ USINESS <br /> Name of Busine$s: 14& �1.:=-'. 1' _ t L. " KAA <br /> Contact Person: `f 5ro" Telephone: {htS ) - ' <br /> Physical Address: ''" �4-S Nub' <br /> Mailing Address: 461--b--- •, ' <br /> E. DESCRIPTION <br /> Type of Discharge: 1 f�.lPsllrCl► UJ? 17 L1�:nx�t�y v� �� �� 00�-� •Ac-mSVI <br /> Volume: <br /> Chemicals• <br /> Circumstances: <br /> E if <br /> F. ACTION TAKEN f <br /> SITE DISPOSITION sus-- +C 9&54iw v�b-. 4th . fl <br /> N 1 <br /> EH 22 013 (Rev.4/91) , <br />