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SAN JOAQUIN COUNTY ..,� <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFE6j <br /> A. EMERGENCY LEVEL: Oil III PHS-EH LOG #IC-1/- <br /> (Circle One) <br /> B. SOURCE PF INFORMATION <br /> Name: Phone: (Z/6-y <br /> Company: <br /> Address: ?— - ,Ca . 91053 <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: X130 a,). a2d.4'"ky"- <br /> (Best Physical Description) (City r County) Circle One <br /> Date of Discharge: __ 1 <br /> Date Notified: S• Z3-9/ Time: <br /> D. RESPONSIBLE PERSON/BUSINESS 'n <br /> Name of Business: R/1? <br /> Contact Person: Telepho <br /> Physical Address: �1�3o GtJ. G!/ao vim . 454- ?Szo 6 <br /> Mailing Address: ,,oA,.,e <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN /moo <br /> SITE DISPOSITION — <br /> AVON- 4-1-G s j -e- — <br /> C8 fat <br /> EH 22 013 (Rev.4/91) <br />