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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I2 III PHS-EH LOG # <br /> '1 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION �} y6�- 3�6�• <br /> Name: Phone: Lam_ <br /> Company: <br /> Address: 22z w�c ' •4v.E- ' i <br /> Designated Employee Name: 1: Phone: �} <br /> Reporting Agency Name: ! 6 <br /> Address: -541V S-a4Q L;-r / 5'i Syc' �a�t✓ CA- -5z c] / <br /> C. LOCATION AND DATE OF DISCHARGE i+ S <br /> Location: 'z s�rLE' syr�f ,���s,4�L onl� fw p/ 5��'rrr��/ ic <br /> (Best Physical Descn* tion) i (City or County) Circle One '. <br /> Date of Discharge: <br /> Date Notified: Time: /J 14;f <br /> D. RESPONSIBLE PERSON/BUSINESS '+ h <br /> Name of Business: <br /> Contact Person: 1� Teldphone• FX 3W,(~ �S6 <br /> Physical Address: AD : S <br /> F . c.Q g.5w,9=` <br /> Mailing Address: 99 '76 ��� �� �� <br /> I' r <br /> E. DESCRIPTION ► <br /> Type of Discharge: r� <br /> Volume: r2R.cJs �yA�Ti4h�rV.4 i�'/JG T (�(c�a.?�J h c /`tdr�YE rl1EFr � <br /> Chemicals: r'ia moi` vya ,mss-r,015 <br /> Circumstances: fG <br /> F. ACTION TAKEN ry A75-417E1,12642;, _.r/D�ir/G' - L <br /> AY ihSE seizef �ft F34 42 <br /> A 17M <br /> s.Gr.iv <br /> SITE DISPOSITION fGI <br /> �Aair N6 c s/ vim <br /> II G <br /> a <br /> EH 22 013 (Rev.4/91) �+ <br /> A <br />