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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE n <br /> HEALTH & SAFETY CODE 25180.7 VLF <br /> !3 <br /> y h <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # G U g <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> , �-= Phone: <br /> Name: <br /> Company: � nPC", <br /> Address: n tc ►Srac� � L� d� <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: ?�O �L 2— <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Description) (Ci r County) Circle One <br /> Date of Discharge: <br /> Date Notified: r Time: <br /> M ! <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: a <br /> Contact Person: --::-telephone: O <br /> Physical Address: _- C2 b S. gt� L, = - L-AF2. � <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: L__ _f1 --- <br /> Volume: 2- A.( a xj s <br /> Chemicals: _�; !_ wiz -n za <br /> Circumstances: <br /> F. ACTION TAKEN <br /> d <br /> SITE STATUS <br /> EH 22 013 (Rev.4/91) <br />