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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHAR <br /> HEALTH & SAFETY CODE 25180.7 [D <br /> A. EMERGENCY LEVEL: I) II III PHS-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: )P,mak: r ,^.1c,�I Phone: T� 5 3X-�,�6 w. <br /> Company: v r'C�r t,t. l.Q <br /> Address: �C, 0l 1<Lkk-'L f� /'!n i!r< r <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Desc4iption) (City or CountyY Circle One <br /> Date of Discharge: �— <br /> Date Notified: d-ll • Time: ' c; .r • T <br /> D. RESPONSIBLE PERS N/BUSINESS <br /> Name of Business: <br /> Contact Person: L64,en-�' c r�-t.'>.�d ` Telephone: 7 3� ! <br /> Physical Address: <br /> Mailing Address: C; <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume:a-i�wk- <br /> Chemicals: <br /> Circumstan es: ,0(.n1 <br /> F. ACTION TAKEN `J1.yyy4nw v= d 2..J,ty ^�.�....� / %�,�'�'2LZ t�'�� /t '�ir�? <br /> SITE STATUS_. <br /> .,.,t?- ,1-.1�- '1(<�-.'.��t.��� �./�i.✓`-Y'-(.il, � �;'!�i"it,..t,� - � /�.� t ;.'..moi Nt.(a -i.,..t.�.c.(; <br /> y . <br /> �i1 i.l -. ,�.u_�:.t ,'�n,�.�-(. �✓t, �� t4 C-':'.�u�" � 'I.L� /%l�f�ti:�1 X11 Cv� • l)-1�'r„ '„�F.,x-/'� �{,� <br /> � � I <br /> EH 22 013 (Rev.4/91) <br />