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r Cnll:- C. <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 C(0[Ply <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: �9 <br /> Company: Phone: <br /> J� lc�� �i < <br /> Address: <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address:_ 4 u S-- t-1 Sa e i 5 t <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 'gn2 �Qr / <br /> (Best Physical Description) 1 or CouncO <br /> Date of Discharge: F5-_ ss <br /> Date Notified: L•=' g r Time: /0, 3o A m <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: /-1< pg- <br /> Contact Person: t4 Telephone: <br /> Physical Address: Q -) (' \ �� P�t� 01. 9 <br /> Mailing Address: I C) �1_ . . /od• A 1 s�5z0 <br /> c. DESCRIPTION <br /> Type of Discharge: -7 K_r[ <br /> Volume: r)— 4 p, Q - <br /> Chemicals: <br /> Circumstances: + <br /> F. ACTION1 TAKEN <br /> ch '. <br /> A -7 1A <br /> SITE STATUS <br /> EH 22 013 (Rev.4/91) <br />