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S <br /> AKI JOAQUIN COUNTY <br /> NfJTI ZTIaNAN <br /> WASTED {�E'•k :+ .-a .,w f <br /> -- HEALTH & SAFETY COD 2si8�}.� <br /> to .r. .... .e- }•.a •f.fa. y ..+1` i} .. _ 1 A. EMERGENCY;LEL94cle <br /> II FIBS-EHL <br /> Chie '`1�) <br /> B. SOURCE OF INFOl1MATiCIN <br /> Name: .. .�. :�;..-„ _ .�.., Phone: <br /> Company:. „ <br /> Address: �}' Ti'3 - -'�141,A , ; <br /> Employee -76 <br /> Designates Employee Name: hone:` 4 <br /> Reporting Ag CY Name:' <br /> Address. , .Q <br /> C; LOC.ATI N AND DATE OF DISCHARC E <br /> >� <br /> . Location: <br /> (Best Physical Description) (Cit-or ounlyj Circle One <br /> Date d:Discharge: U td 1<w 0 W' r- <br /> Bate Notified; - ---7_- --- f Time p o a/' <br /> I) RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: t'��,� 55 �nl. / 6, -- +fir Zt4t& <br /> G <br /> Contact Person "r s gkgrS A44 ir.Telephone: (7ZDS!3 5---7-7, <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals-. c '`vR s <br /> Circumstances: 1, 'r- nEoi.,. . ' ► ` <br /> , <br /> ZAZ •.. <br /> F. AMON"TAKEN :O 10&0 5 <br /> 1,7 <br /> AL OArc� <br /> SITE DISPOSITIONC.# �> <br /> t1A 9+1A <br /> v r e.. <br /> Ny 12 orrt a. fes.' Re6 <br /> EH 12:013,(Re'v.4/01'1' <br />