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• SAN JOAQUIN COUNTY • <br /> voplrNOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III <br /> PHS-EH LOG # / w <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: l' Phone: (�) 5?1-o9G7� <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: (� <br /> Reporting Agency Name: <br /> Address: :_���E � G <br /> C. LOCATION AND DATE OF DISCHARGE / <br /> Location: 24Ol ( � , - A-va <br /> (Best Physical Description) (City oj< o Circle One <br /> Date of Discharge: <br /> Date Notified: Time: /: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: i rola i r-—H a kN <br /> Contact Person: Telephone: (2&*) W05-- 32M <br /> Physical Address: 12Qn 1 <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: 4d 1 0 mac• �► "` <br /> Volume: <br /> Chemicals: e <br /> Circumstances: <br /> Lo�.�. O is <br /> ��� ¢�� � <br /> n �sb.1 <br /> F. ACTION TAKEN-��� ,-- �— <br /> SITE STATUS <br /> a <br /> EH 22 013 (Rev.4/91) <br />