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SAN JOAQUIN COUNTY <br />NOTIFTION OF HAZARDOUS WASTE D1�ARGE <br />HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVEL: III III PHS-EH LOG # 17/ <br />( ircie One) j 3 V-) <br />B. SOURCE OF INFORMATION <br />Name: cam. A"_� '3 Phone: q b <br />Company: <br />Address: <br />Designated Employee Name:. i1 Phone. N , <br />Reporting Agency Name: <br />Address: " <br />I <br />C. LOCATION AND DATE OF DISCHARGE <br />-Location: 5:56_ 3 S - R , r M r-i- Lc, a.L <br />(Best Physical Descn tion) '} (City or unty e One <br />Date of Discharge:it <br />Date Notified: 1 `t t Time: 3, 4 pD <br />D, RESPONSIBLE PERSON/BUSINESS I' <br />Name of Business: ca444 n <br />Contact Person:- o- C. r 't U Telephone: an ql;?- 4 C 73-,_ <br />Physical Address: 6su,3 5 <br />Mailing Address: <br />E. DESCRIPTION <br />Type of Discharge: <br />Volume: <br />Chemicals: t.. u t c. C_L e_ Q e.,. � ox's c.. �. Q 1 <br />Circumstances: e.v i e o D-j; <br />;e <br />F. ACTION TAKEN <br />EH 22 013 (Rev.4/91) <br />