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SAN JOAQUIN COUNTY <br /> NOTIFI( TION Or IL -ARDOUS WASTE ISCI-TARGE <br /> 13I✓ALTH & SAFETY CODE-.2S <br /> i <br /> l `�f u d i <br /> A. E-MERGENCY 7 EVELO II III <br /> PHS-EI-i LOG # 1 3 <br /> (Circie One) ,. _ .ii <br /> B. SOURCE OF INFORMATION g.ry _ <br /> 11. cr,p Telephone: 7 �v <br /> � <br /> original Source: <br /> RI!parting Agency Name: <br /> A en Contact: Telephone: 0 4 '1��vS � /a D <br /> g cy n <br /> Asa <br /> o <br /> RIO. &6Xx aoo <br /> Address: <br /> C. LOCATION AND DATE Or DISCHARGE <br /> L��ocadon: � 5 � r �� 1 {City or County <br /> (Best Physical Description) ) <br /> I t <br /> Date of Discharge: `o <br /> 11 fy �v ?d Time: <br /> Date Notified: <br /> D. RESPONSIBLE PERSON/BUSINESS DD <br /> Name of Business <br /> I ,o Telephone* <br /> Contact Person: LI <br /> p (---� <br /> Physical Address: f � <br /> E. DESCRIP'T'ION , <br /> Type Release: 77 <br /> � <br /> �7olume; <br /> Chemicals: <br /> r. E ACTJON TAKEN ' <br /> ,i. <br /> ! <br /> EH 22 013 (Rev. 02/90) <br />