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I <br /> SAN JOAOULN COUNtIf <br /> NOTiFIC.�.TION OF HAZARDOUS WASTE DISaiARGE FILE CI <br /> HE,-I.TH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LZ EL:QII III PHS-EH LOG T# <br /> {Circle One) 1 <br /> B. SOURCE OF INFORMATION II <br /> Name: M a Phone: an <br /> Company: <br /> Address: <br /> Designated Employee Name: '- fi e,�— i S Phone: C2 M L77 x )11 , - <br /> Repordnv Agency Name: <br /> Address: 1 <br /> C. LOCATION AND DATE' OF DISCHARGE <br /> Location: <br /> U � <br /> (Best Physical Desczipnon) (City c County Circle One <br /> Dare of Dis&-arge: <br /> Date Noaaed: !Y �L Time:. <br /> D. RESPONSIBLEE PERSON/BUSILLNESS Zl <br /> Namin <br /> e of Busess: 1. lav p <br /> Contact Person: c? Telephoae: r � <br /> Physical Address: t i % Ole rr 16, <br /> J <br /> Maillila Address: r <br /> a <br /> E. DESCRIPT ON <br /> Type of Discharge: ' <br /> Volume: <br /> 67 <br /> _ r <br /> Chemicals: r <br /> 13 <br /> Circumsr ances: G�e <br /> P. ACTION TAKEN J <br /> !.� <br /> o <br /> r <br /> SITE S T ATli S <br /> EH 22 013 (Rev.4/91) <br /> h <br />