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- COUNTY FILE COP <br /> SAlN JOAQUIN <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG# 03- 0�6 <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Name: J I Yyl �4�U 1 S Phone: (Le°� b <br /> Company: • -T <br /> e jC pv� G4 9 0 <br /> Address: 0 4C) W-46#- LN <br /> Designated Employee Name: h M�►J Vlr+i Phone: ct- <br /> Zoe 6 <br /> r.1 0 A Qv" D• k)lJi�M lit.L9'( b/�9 <br /> Reporting Agency Name: S4 '51100 <br /> Address: 3DB( <br /> C: LOCATION AND DATE OF DISCHARGE <br /> Location.. L4tty r County) Circle one <br /> (Best Physical Description) <br /> Date of Discharge: 2 63 <br /> Date Notified: Time: E.'342 D /''1 <br /> D. RESPONSIBLE PERSONIBUSINESS <br /> Name of Business: n6 rK 41) _ <br /> Contact Person: �e. 0 Phone: 00 b 22 <br /> f <br /> Physical Address: 111 Q C D7 <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: P <br /> Volume: ^- �lcatiS <br /> Chemicals: fA e <br /> w er <br /> Circumstances: R <br /> F. ACTION*17AKEN <br /> C1 �� " <br /> ova an It%Lil a'� �:Ot�.►,, <br /> SITE DISPOSITION Vo4- <br /> EH 22 013 (Rev. 08/20/98) <br />