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SAN JOAQUIN COUNTY <br /> NOTIA TION OF HAZARDOUS WASTE AMtHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:0 II III ( <br /> PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: 2 95'7.53 <br /> Company: <br /> Address:_ -SSS Gr/• & r - SG eY- 'ss doh <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: (0 6 i E. !�2� <br /> (Best Physical Description) ty r County) Circle One <br /> Date of Discharge: � . <br /> Date Notified: 3- 30—Y2— Time: 8� <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: 64-C� Telephone:P (22L) 5-z3 • PioO <br /> Physical Address: <br /> Mailing Address: Joao C�. P d•a— �(/ o Esso <br /> E. DESCRIPTION <br /> Type of Discharge: ti <br /> Volume <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN 4 66r of <br /> _ rt <br /> 3 <br /> SITE DISPOSITION _ ��e�f �,�)!o .�/ ys Eye Q+ti., L04 <br /> GAAL <br /> EH 22 013 (Rev.4/91) <br />