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SAN JOAQUIN COUNTY .J <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:(g�lII III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: <br /> Name: (� <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: L� <br /> Reporting Agency Na¢-e: <br /> Address: �cf� �l Sri T�94vti S`� io �j vSLo( <br /> C. LOCATION AND DATE OF DISCHARGE Gop/ <br /> Location: 6 ?Y <br /> (Best Physical Descri tion) I City r County) Circle One <br /> Date of Discharge: D' u��! <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: wT,'2,0 <br /> Contact Person: ��9c-6 Telephone: <br /> Physical Address: 68'i G v F � s' mac'' q52 n <br /> Mailing Address: - <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: o <br /> Circumstances �i coy �o oG�ssE�yF� Av ei G � ^/� <br /> F. ACTION TAKEN —7--3A1e --�42 dez moy�� <br /> S_ITE STATUS <br /> �F—S6�i. F • '���'� �0�o/a.2 i–,r-�c ate– '�`��r cy� <br /> EH 22 013 (Rev.4/91) <br />