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SAN JOAQUIN COUNTY 0 <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7r <br />C CU �r <br />A. EMERGENCY LEVEL: I 116P PHS -EH LOG # C� -G,9 % <br />(Circle One) <br />0. <br />C. <br />D. <br />E. <br />F. <br />SOURCE OF INFORMATION <br />Name: r 'Cke/ G <br />Phone: zo- 9-33 - `/936 <br />Company: S�e��g<zed( �� ��,,�. ��� ►nn 4K45 ��� t, jvkL <br />Address: f,53 74 <br />Designated Employee Name: calm } Phone: (om.))y62--c33v <br />Reporting Agency Name: �v�1;` <br />Address: iy• m y!� S„ S� ' S k� M , <br />LOCATION AND DATE OF D <br />C4 J a 4 ; �► <br />(Best Physical Description) (City o�G a One <br />Date of Discharge: G - a Y - 5-3 -- <br />Date Notified: G - 5 - 9 -3 Time: 3'- so 4 -,-► <br />RESPONSIBLE PEI <br />Name of Business: <br />Contact Person: <br />Physical Address: • <br />Mailing Address: _ <br />I to 00 <br />DESCRIPTION <br />Type of Discharge: <n, l l A es e ( � <br />Telephone: M`J V3 3 - V'7-3 <br />�I, l� 4< 37t. __- <br />SITE DISPOSITION <br />EH 22 013 (Rev.4/91) <br />