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1 � <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 C 0 Pry <br /> A. EMERGENCY LEVEL: I III PHS-EH LOG / D/ <br /> ( ' cle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: L� <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: (� <br /> Reporting Agency Name: <br /> Address: 2-,=,-2- <br /> C. <br /> c,ZC. LOCATION AND DATE OF DISCHARGE <br /> Location: 2-7 4- <br /> (Best Physical Des 'prion) ty a CounryY Circle One <br /> Date of Discharge: <br /> Date Notified: I Time: L-�i_oo <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: I..r <br /> Telephone: <br /> Physical Address: �� <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: iSn <br /> Volume: <br /> Chemicals: <br /> Circumstances: �� 0 6� �., C-►rt G , c _� �� IFS <br /> F. ACTION TAKEN 4v <br /> SITE STATUS —T-�Ae <br /> EH 22 013 (Rev-4/91) <br />