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SAN JOAQUIN COUNTY <br /> "NOTIFICATION OF HAZARDOUS WASTE DISCHARGEC(D <br />( HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL I I III PHS-EH LOG # <br /> 21 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION c Phone: sl <br /> Name: e a <br /> Company: �' i <br /> P Y� 1 <br /> � P g c 1�c�o ��. 3 <br /> Address: ; <br /> Designated`Employee Name: Phone: tai)'a 6� 33 q <br /> Reporting Agency Name: S4r <br /> Address: �(� X, <br /> Z. Q . <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 2 P 9c s L-- Q. e__ / J�DC vi <br /> (Best Physical Description) Ci County) Circle One <br /> Date of Discharge: �27- -_ 3 <br /> 'Date Notified: -1`t -el Time' <br /> D. `RESPONSIBLE PERSON/BUSINESS <br /> !Name of Business: vvvif 4-; _,�+ cyl r:h TV1►� <f t..3 m r 1� <br /> lContact Person: (ne-0 r a c C, 0 —Telephone: 95!L) ?(16 <br /> ^Ssrs-S <br /> .Physical Address: ZSn 1 J L1_,%s- r 4:::;, � '^ C4 <br /> ,.Mailing Address: Po (0 <br /> E. :DESCRIPTION n <br /> Type of)Discharge: til G v�Zr--J Le-c' 4--rV S -F <br /> ..Volume: I ,A A0"_1 <br /> 'Chemicals: <br /> Circumstances: jz!Coar on %Z+-S T <br /> pvw j <br /> F. ACTION TAK�yEN c� . r a ,t 4 S <br /> SITE ST TUS P L o y Uefs <br /> rn <br /> EH 22 013 (Rev.4/91) <br /> iR . <br />