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• • �GVLS. tI � r <br />SAN JOAQUIN COUNTY <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVE13f II III <br />(Circle One) <br />B. SOURCE OF IyFORWTION <br />C <br />M <br />F. <br />Company: <br />Address: <br />Uesigrated Employee Name: --L'2'4 ,` <br />Reporting Agency Name:__ <br />Address: <br />LOCATION AND DATE OF DISCHARGE <br />Location: ! 4 -! L - V!/1 f� f. ; c <br />(Best Physical I <br />Date of Discharge: 6( - <br />Date Notified: 0, i — <br />RESPONSIBLE <br />Name of Busine <br />Contact Person: <br />Physical Addres <br />Mailing Address <br />DESCRIPTION <br />Type of Discharge: <br />Volume: <br />Chernicals: i Pte' <br />Circumstances: <br />PHS -EH LOG #_ -2 — J %� <br />phone: <br />i ��K <br />(City o oun Circle One <br />f <br />]-&6S <br />EH 22 013 (Rev.4/91) <br />l <br />