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4 SAN JOAQUIN COUNTY <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7 0j` <br />A. EMERGENCY LEVEL:1 11 III <br />( ircle One) <br />B. SOURCE O <br />Name: <br />Company: <br />Address: 7-2,7,1 <br />Designated Employee <br />Reporting Agency Na <br />Address: <br />C. LOCATION <br />(Best Physical Description) <br />Date of Discharge: 62416.0 W <br />Date Notified: �o - ZO -97 <br />D. RESPONSIBLE <br />Name of Businf <br />Contact Person <br />Physical Addre! <br />Mailing Addres <br />PHS -EH LOG # C? / r O <br />Phone: cUuO 'J�Q 0 a <br />Phone: <br />County) Circle One <br />E. DESCRIPTION <br />Type of Discharge <br />volume: �. <br />Chemicals: <br />F. ACTION T <br />EH 22 013 (Rev.4i 91) <br />