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SAN JOAQUIN COUNTY ���� COPY <br />NOTIFICATION OF HAZARDOUS WASTE DISC <br />HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVEI I III <br />irele one) <br />B. SOURCE OF INFORMATION <br />PHS -EH LOG # - Q <br />Name: 'P'O6t'„r} Lope a Phone: (20� giDg - 3qQ() <br />Company: Sq,y\ L (,c> — S <br />Address: e,' V,4L O S Ltn <br />Designated Employee Name: �1Phone: - IR <br />Reporting Agencv Name: _ - V h OVI vt <br />St <br />Address: V -0L1 1=;_WA1CVV AW).1AA0 _ -1-VlW64 ,FIDD/- 5Z02. <br />C. LOCATION AND DATE OF DISCHARGE <br />Location: 1410 0 F, %1'.e m Dy- t ei- <br />(Best Physical Description) (City o `County Circle one <br />Date of Discharge: Ill? 2l� <br />Date Notified: Time: ID'00~ <br />D. RESPONSIBLE PERSON/BUSINESS <br />Name of Business <br />Contact Person: <br />Physical Address: <br />Mailing Address:_ <br />E. DESCRIPTION <br />F <br />Type of Discharge: <br />Volume: <br />Chemicals: CA <br />Circumstanc N <br />C I A �A u L-) r <br />rAV <br />Phone: <br />1EVINIMONVA <br />�. <br />EH 22 013 (Rev. 08/20/98) <br />