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ILE COPY <br /> SAN JOAQUIN COUNTY • f <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL II III PHS-EH LOG <br /> �rcle one) <br /> B. SOURCE OF INFORMATION <br /> Name: <br /> i2S Phone: (� <br /> Company: <br /> Address: S 3 0 <br /> Designated Employee Name: Phone: `7A9 � <br /> Reporting Agencv Name: 3 a 4 d <br /> Address: <,2DV (A3n SIOL C 1� 9S >h Z <br /> C. LOCATION 'AND DATE OF DISCHARGE <br /> Location: t D --"lA4Vl l <br /> (Best Physical Description) tty r County) Circle one <br /> Date of Discharge: O u <br /> < Time: 3 10 p. <br /> Date Notified: <br /> D. RESPONSIBLE PERSONIBUSINESS <br /> Name of Business: ULA ej j` L <br /> Contact Person: Phone. <br /> Physical Address: <br /> Mailing Address: 'Ib 1 )KaC ase S lOo r f° ( F4 �t Zd 7 <br /> E. DESCRIPTION <br /> Type of Discharge: Q V-Q-AJ On� <br /> Volume: <br /> Chemicals: a �� <br /> Circumstances �{L+ I S "` y <br /> F. ACTION TAKEN (_e �ujg <br /> SITE DISPOSITION 40 <br /> EH 22 013 (Rev. 08/20/98) <br />