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SAN JOAQUIiN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG# <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Name: V. C o 2 Phone: (6&) Kofi-I Ha. <br /> Companv: <br /> Address: 'P013(fr x `sCo ac-y, C A `sz of <br /> Designated Emplovee Name: Phone: <br /> Reporting Agencv Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 2 Z. 1 STOP L <br /> (Best Phvsical Description) City or County) Circle one <br /> Date of Discharge: . <br /> Date Notified: o Time: : <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: (Dk'y) ' t_:2v. n,n)A L 4 - <br /> Contact Person:_ Phone: • o - k- got. <br /> Phvsical Address: i ST ,C�-TQ - <br /> 1VlaiiingAddress: N =2Tr�caLt�+ ) <br /> E. DESCRIPTION <br /> Type of Discharge: ' <br /> Volume: A}r)j NOCJA) - <br /> Chemicals: r= 'c n r'ti'<• -� } <br /> Circumstances: , <br /> s i <br /> F. ACTION TAKEN <br /> SITE DISPOSITION = z� <br /> l C- G <br /> EH 22 013 (Rev. 08/20/98) <br />