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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180. 7 O nM <br /> A. EMERGENCY LEVEL: 0 11 III PHS-EH LOG # u <br /> (Circle One) <br /> 3. SOURCE OF INFORMATION <br /> Name: #2A -5. Phone: 91 i7 7 - 2-? f 1 <br /> Company: C0 <br /> Address : 211c'0 Ckff*j - —moi �t Pot) C . 2aM a, C/b q6n <br /> Designated Employee Names : Phone: L..) <br /> Reporting Agency Name- <br /> Address : <br /> co LOCATION AND DATE OF DISCHARGE <br /> Location: fF6o6 'rl� � Pit <br /> (Best Physical Description) §or County) Circle One <br /> Date of Discharge <br /> Date Notified: [ t Time: 100P . A <br /> D . RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: oSc_,o ✓ &AIA -( <br /> Contact Person: \�j Telephone: ( o -79 - Z 3�I t <br /> Physical Address : <br /> Mailing Address: C� Kt, S r , ti q&v CAS S �P�83 <br /> E. DESCRIPTION l v��t <br /> Type of Discharge: <br /> Volume: ( 12 <br /> Chemicals : n <br /> Circumstanc . n �3. _rte C t � � ��uu s -faLt o P,u <br /> F. ACTION TAKEN A-eU4, Lz&, &A;�f *v - �^- L �l �l �l W6� 3 no .� <br /> tl 9z7 <br /> SITE STATUS Oma—AZ zg&ge:jw <br /> !X <br /> CSG <br /> C <br /> EH 22 013 (Rev.4/91 ) <br />