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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE • <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. <br /> EMERGENCY LEVEL: I II III PHS-EH LOG # X <br /> �� � • . <br /> (Circle One) <br /> B. <br /> SOURCE OF INFORMATION <br /> Name: Phone: (_Zcw <br /> Company: �- �' a ✓n <br /> Address: l 3 c( w ��,44E <br /> Designated Employee Name: Phone: (T) <br /> Reporting Agency Name: <br /> Address: 3en-/ sem- sTA <br /> d. <br /> C. LOCATION AND DATE OF DISCHARG� <br /> Location: 13o r ;Z-. /�',,e7 ,4 <br /> (Best Physical esc ption) �r County) Circle One <br /> Date of Discharge: 3v9b <br /> Date Notified: "-7 Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: G ote- Gi vv <br /> Contact Person: � C-. � <br /> � 4 Telephone: ) - 233 <br /> Physical Address: 13 a MR,F-r <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: .� ✓�7 <br /> Volume: '► /o <br /> Chemicals: <br /> Circumstances: 4 <br /> F. ACTION T N ,eEr.�S{ �S Gc�►�it �� �� �-�illc_ �-� `���' <br /> � <br /> SITE STATUS o2c coo��` �r►s o s <br /> EH 22 013 (Rev.4/91) <br />