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SAN ]OAQUINCOUNTY <br />NOTIFI48I7ION OF KA7,ARDOUS WASTE*SCI-IARGE, <br />HEALTH & SAFETY CODE-' 25180.7` <br />A. EMERGENCY LEVEL OI II III <br />(Circle One) <br />PIIS -EH LOG # -- 4() " / 3 (� <br />B. SOURCE OF INFORMATION <br />Original Source: Ca.Q %jSiiTelephone: (v16%) Lt75 0& <br />Reporting Agency Name: ,�OvntJJLC& <br />Agency Contact:�1..1aL� <br />Address: P, 0. �(� aO D l <br />Telephone: -3,/a d <br />C/�L D / <br />C. LOCATION AND DATE OF DISCHARGE <br />Location: 5�V5 F <br />(Best Physical Description) (City or County) <br />Date of Discharge: <br />Date Notified: 6 �d <br />D. RESPONSIBLE PERSON/BUSINESS <br />Name of Business Le) 9 �i5 cvyt� <br />Contact Person: <br />Physical Address: _2_0, c)o * <br />E. DESCRIPTION <br />Type Rel <br />Volume: <br />Chemical <br />F. ACT�I,�OeN'�-�..a,, <br />01 <br />%C1�2 1/ •f #� n <br />Time: <br />Z Telephone: <br />4 <br />lr�. <br />EJH 22 013"(Rev. 02/90) <br />