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e SAN JOAQUIN COUNTY (f <br /> NOTIFICA�fION OF HAZARDOUS WASTE DISLAARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:� I,�'II III y PHS-EH LOG #G/tom �q <br /> ( ucle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: Cj.,0 q4- -C11 / <br /> Company: _? <br /> Address: <br /> Designated Employee Name:, +; L' ti 'O e G�(- Phone: 40 <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE 4 <br /> Location: 1-S00til. Isa1cJ 72.��-t / •s{Dc �'�"�'� <br /> (Best Physical Description) , (City or n Circle One <br /> * ou <br /> Date of Discharge: <br /> ter ,Gn�».Fz L"Yr� <br /> Date Notified: / — i 7 — 9.2— Time: lC; CC , <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: (104) X70 <br /> Physical Address: ,.inn A), S/ f5:--1r1- <br /> Mailing Address: SQ'? <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: 4-( -Sc4t�t-� <br /> Circumstanc s. <br /> F. ACTION TAKEN ^ r, L-t,,LYV <br /> - <br /> ti <br /> -J <br /> SITE DISPOSITION i 0 0 , t >CC �t2 t r<�• �'t _1 <br /> EH 22 013 (Rev.4/91) <br />