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SAN JOAQUIN COUNTY 'J— <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 � 0 P�U/ <br /> A. EMERGENCY LEVEL:011 III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: 3 /� Phone: <br /> Company: 1C • UjaaZ <br /> Address: OSa .GLeQo o p� <br /> Designated Employee Name: Ph ne: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 30/l d/. <br /> (Best Physical Description) Dor County) Circle One <br /> Date of Discharge: &-X�` <br /> Date Notified: 114 &95 Time:z4e,= <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 644ZQ OSP a . <br /> Contact Person: 4a—, Telephone: Cf o) /v 7S /& <br /> Physical Address: <br /> Mailing Address: o• 3a,C oaf Sa <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN <br /> G'Bx <br /> SITE DISPOSITIONQ <br /> n <br /> EH 22 013 (Rev.4/91) <br />