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�we SAN JOAQUIN COUNTY <br /> NOTIFICA'ION OF HAZARDOUS WASTE DISCHARGCOPY <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL I II III PHS-EH LOG # <br /> ircle One) <br /> B. SOURCE OF INFORMA_TI N � �_sl <br /> Name: Phone: <br /> P Y <br /> Com an <br /> Address �i rT ` � �� U <br /> Designated Employee Name: Phone: (� <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISC <br /> Location: ( l' L-OC k-Z , S� <br /> (Best Physical DeDescription) Ciiption) rY r County) Circle One <br /> Date of Discharge: +n vtLdl Or <br /> Date Notified: let Cr / 9,3* Time: 30ci"� <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: tv (- � �- <br /> Contact Person: ab jo_ C.¢- Tel�!phone: <br /> � <br /> Physical Address: 3�Q W 2 � linn?1��o �� Ub1 N S5 3 5 <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: + <br /> Circumstances: y uv e,V' w S <br /> F. ACTION TAKEN Gt VE 'rgZU� A LY\" fpmzNeoj <br /> SITE STATUS S a s La <br /> EH 22 013 (Rev.4/91) <br />