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�AN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> i HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH'LOG:# <br /> rircle One) <br /> B. SOURCE OF INF R ION <br /> Original Source: `Gt �� Telephone: _) <br /> Reporting Agency Name: <br /> Agency Contact: � `T �- ,, Tele phone: <br /> Address: R a-O 4 1° �,2 <br /> C. LOCATION AND DATE OF DISCH A,RGE <br /> Location: �3,�3 0- -A� / 2 '" / cr <br /> (Best Physical Description) 11.(City or Co nty) <br /> Date of Discharge:, __�JjA q'i -- <br /> -�' i 3 v <br /> Date Notified: /o'Z 1 �G� Time: <br /> D. RESPONSIBLE PERSON/BUSINESS 1° <br /> f <br /> Name of Business <br /> Contact Person: Teleph ne: (_1I } <br /> Physical Address: <br /> D i, aJ� <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: <br /> Chemicals: <br /> F. ACTION TAKEN <br /> JI <br /> G <br /> c <br /> C = 0. V/ s� <br /> a4� as <br /> RC <br /> � c <br /> EH 22 013 (Rev. 02/90) <br />