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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL I JI III PHS-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> e Phone: <br /> Name: (� <br /> Company: C_ <br /> Address: 3 e- <br /> Designated Employee Name: Q e S Phone: ((o ,355-3 ooe <br /> Reporting Agency Name: C 0,11-C <br /> Address: 3 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: P / <br /> (Best Physical Description) (City or oun ircle One <br /> Date of Discharge: Lo (� <br /> Date Notified: Time: I <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: �e..n C ate-be� rc,_c 5+v ick <br /> Contact Person: P, �A-� Telephone: o� 9 9 5 —X14-72 <br /> Physical Address: <br /> Mailing Address: (��E-c64 '1 f'sE. DESCRIPTION �� <br /> Type of Discharge: L <br /> Volume: <br /> Chemicals: e— <br /> Circumstances: 7 Fio` 4t,61 `^ C,� <br /> F. ACTION TAKEN �A <br /> SITE STATUS LV R Ls) t� t e cu' S t 'L'J—) <br /> EH 22 013 (Rev.4/91) <br />