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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISIPARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL(D 11 111 PHS-EH LOG # of, <br /> 07cle, One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: <br /> ? or a phone: QLo <br /> Reporting Agency Name: <br /> Address: LY!j S �t-z ?-I <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 2C2 7 D W.- yoserA. mni ke C.1 <br /> (Best Physical Description) or County) Circle One <br /> Date of Discharge: <br /> Date Notified: 57- 1Y . 9 ?— Time: 3 :30dwi <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: r a.4 V-.'5 <br /> Contact PersonTelephone: (Z <br /> 41 Physical Address: Z.0-r Z- U - Y0.5, M n-4 c <br /> Mailing Address: Y"', Qla. ev <br /> 91-76 Ccwc.- <br /> E. DESCRIPTION <br /> Type of Discharge: j <br /> Volume: <br /> Chemicals: <br /> Circumstances: 4-3- 92 ed.4 <br /> In; <br /> F. ACTION TAKEN <br /> goicel=(f�, 0-4 rccc. Ic <br /> 6 1 1 <br /> Y2- f,- 4,-, ' A LA?5 A4 <br /> �4\ L -a- Ic 6.1 C-S S 1C, LN a e- <br /> .e'l <br /> -,% 7 It <br /> SITE DISPOSITION -7—,4 �20 <br /> 7'10 <br /> EH 22 013 (Rev.4/91) <br />