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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> r <br /> � <br /> _l:/ <br /> A. EMERGENCY LEVELGI II III PHS-EH LOG #_ ! 7 <br /> (Circle One) <br /> B. SOURCE OF INFO TION <br /> Name: Phone: (moo S6-dab y <br /> Company: t <br /> Address: 3 <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name //—//s, <br /> Address: <br /> ell <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location:_ 500 4 <br /> (Best Physical Description) Ci r County) Circle One <br /> Date of Discharge: <br /> Date Notified: 14y Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: elephone: Lyy9) <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume <br /> Chemicals: S �' <br /> Circumstances: E <br /> F. ACT ON TAKENgill la�!r <br /> S 3 <br /> D <br /> /L 3• z <br /> G i3� 9 <br /> SITE STATUS US G e <br /> 6 <br /> o/ PY�2trJ ax <br /> EH 22 013 (Rev.4/91) <br />