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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 251 <br /> COPQ <br /> A. EMERGENCY LEVEL II III PHS-EH LOG # f ! — O <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: v� i'Y1 n Phone: �a9 y� <br /> : o-m ,t2 Companyn U , rdm F� e <br /> Address: a <br /> Designated Employee Name: a e Phone: (_) <br /> Reporting Agency Name: tt <br /> Address: 4LI-S Q <br /> C. LOCATION AND DATE OF DISCHARGE `�_�� <br /> Location: 114 a l (u r n <br /> (Best Physical Description) Ciry r County) Circle One <br /> Date of Discharge: Ow V\- <br /> Date Notified: ry rt Time: L4:DO P <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 4e r 60 r L <br /> Contact Person: D u r\c- . Ke , r Telephone: a-n 5aV a a3 a <br /> Physical Address: ( 00 0 l u v\ t <br /> Mailing Address: I t n (anal C 1- VYla�es <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> volume: <br /> Chemicals: <br /> Circumstances: edl 6-r- - R nD `(° r <br /> cd�ora a Sor r�Z S /e"/yt J <br /> F. ACTION TAKEN <br /> SITE STATUS <br /> EH 22 013 (Rev.4/91) <br />