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OPYSAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I III PHS-EH LOG # l <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: 3 Y' <br /> of C---S Phone: �(y <br /> Company: J <br /> Address: <br /> Designated Employee Name: G�r S Phone: <br /> Reporting Agency Name: J <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE, <br /> Location:—s. y3._�. �"�.'zG.:� y,,�ZG2 n. 41. / <br /> (Best Physical Description) (City or6uty�(Circle One <br /> Date of Discharge: <br /> Date Notified: Time: / / 3 c <br /> D. RESPONSIBLE PERSON/BUSINESS � . _ <br /> Name of Business: c ' ? -b �e7 a p <br /> Contact Person: Pit S 7 kj Telephone: "LD '�- <br /> Physical Address: cg, 4' �=5 71 <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: &L. /0- <br /> Volume: <br /> 0-Volume: rs- - <br /> Chemicals: -u �,--4- <br /> Circumstanc s: <br /> F. ACTION TAKEN <br /> GZ � <br /> cz� LT- <br /> SITE STATUS <br /> C! ( �� :� 1/ -Lf 77 <br /> EH 22 013 (Rev-4/91) <br />