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FA <br />B. <br />SAN JOAQ UIN COUNTY <br />NOTIFICATION OF HAZARDOUS WASTE DrSCI-LARGE <br />HEA I H & SAFETY CODE 25180.7 <br />E?'Vf-=RGENCY L VEL: IQ II DI <br />(Circle One) <br />ZGi;Z761Z <br />FILE COPY <br />PHS -EH LOG :r 9g • ` 0�D <br />SOURCE OF INFORMATION <br />Name: L --<c-,, `f' -i t e, 0 5 Phone: E -63 26 3 Y6 <br />Company: <br />Address: <br />Designared Employer Name: ` a-, r ' Phone: <br />Reporting Agency Name: <br />Address: <br />C. LOCATION AND DATE OF DISC <br />Location: T l '/7 E, 1 <br />(Best PhysicaL Desaipt <br />Dare of Discharge. iz,-� <br />Dare Notified: 7 --,;Z -7 <br />D. RESPONSIBLE PERSON/BUSINESS <br />Name of Business: C-. <br />Contact P -.=c : <br />Physical Address: <br />Mafling Address: 14- 11� <br />F. <br />'ir=e: rn <br />DESCRIPTION <br />.- of Discharge:i <br />Vol=e: it _'�[ w►Jr <br />M.einica I <br />r� <br />Telephone:. <br />ri m r, i - - <br />AP <br />A i k/ f- I <br />E -H 22 013 (Rev.4/91) <br />