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SAKI JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DIS(�)IRG <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:a II III PHS-EH LOG # GQ>�, <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: dam-D T,e� Phone: Cz/z, <br /> Company: '� o5 <br /> Address: _F/o. <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Description) ((City r County) Circle One <br /> Date of Discharge: <br /> Date Notified: !D- Z-6 -12, Time: <br /> D. RESPONSIBLE PERSO '/BUSI,?ESS <br /> Name of Business: <br /> Contact Person: LX—LAA o e C'E Telephone: /6 -36 P J'r; <br /> Physical Address: 7 "`3�0 <br /> Mailing Address: ; <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> y"Z L 2 C 0- <br /> F. ACTION TAKEN <br /> ,V Q G <br /> SITE DISPOSITION <br /> ✓jLQ�'`.0-c2 � <br /> EH 22 013 (Rev.4/91) <br /> /b1L���z <br />