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• SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DIAARGE <br /> HEALTH & SAFETY CODE 25180.7 C �J <br /> A. EMERGENCY LEVEL: I II 6) PHS-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: �) <br /> Company: <br /> Address: <br /> Designated Employee Name: I t_ R' ,T -77 Phone: <br /> Reporting Agency Name: (7n C. flIIS-fit+� <br /> Address: 9 4 S N. S,�n <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: --fob L3,-- .�2 A-Q<, Pa, <br /> (Best Physical Description) (City or Co ty) Circle One <br /> Date of Discharge: koc>, <br /> Date Notified: 3-`i- cr-3 Time:_ II'• oo gr, <br /> D. RESPONSIBLE PERSON/BUSINESS n <br /> Name of Business: C'l,e�ro g f ;A e <br /> Contact Person: PlAre 4r•re Telephone: 510 b S-o -3160 <br /> Physical Address: 7-1 G le-To P_1}sb_„r r_+ !, ;YS6-r <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: _ 44 <br /> Volume: <br /> Chemicals: F f� <br /> Circumstances: Ur.Qr v, j �ls,\t .,,141,1 � o� �s 10�— <br /> r� }cwala� f s,�rl <br /> F. ACTION TAKEN cc`, l 4 N5 lin . <br /> to v a4 <br /> yle <br /> a�C <br /> SITE DISPOSITION ::nLi s <br /> _ rrt/roc �1on ,1 /' Clic_ �' /✓(�(' `�'i <br /> _ oll r4oA.�S it vlt d/9//0+7 <br /> EH 22 013 (Rev.4/91) QX <br />