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m � <br /> SAN JOAQUW COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISO`T-IARG£ <br /> & SAF✓17 CODE 25180.7 <br /> — LMERGENCY iZT Pu-S-FSIOG �y q7- <br /> L T <br /> 3. SOURCE OF INFORMATION <br /> Name: D�h, Phone: S 6 <br /> Company: /�/Gz Foca <br /> Address: o <br /> gn <br /> Desiated Employee Name: D phone: <br /> Reporting Agency Name: 1-12 �l; f�Pa " !� „ �fi ,,.► <br /> Address: �� Ut/ tri' 7 r1�/ Sri 3� Gi4 S rss <br /> C. LOCATION AND DATE OF DISCIiARGE <br /> Location: 03 5 O S. Lir' <br /> (Best Physical De4ciption �r aunty) Circle One <br /> Date of Discharge: <br /> Date Notined: Time: / Jli/ ti <br /> r ,D. RESPONSIBLE PE.RSON/BUSuN-E"S <br /> Name of Business: -ceJT <br /> Contact Person: Tele hone: ( ) <br /> Physical Address: /� / <br /> Mailing Address: <br /> Type of Disc^a oe: / <br /> Volume: / <br /> Chemicals: <br /> Circ-.=ta.nces: <br /> F. ACTION TAlMiv_ <br /> SITE STATUS <br /> EH 22 013 (Rev.4/9I) <br />