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SAN JOAQUIN .COUNTY <br /> NOTIFICA N OF HAZARDOUS WASTE I)•CHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # gel) <br /> (Circle One) <br /> B. SOURCE OF INFORMATION _ � / <br /> Original Source: ji� a Telephone: ((�6q y4,6 ,rjf <br /> Reporting Agency Name: S e6 <br /> Agency Contact: ( Telephone: (cz� <br /> Address: f 2SD <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: / <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: <br /> Date Notified: / a-7 — q D Time: 3 �' <br /> D. RESPONSIBLE PERSON/BUSHINESS / p <br /> Name of Business es�' �! gf-kd G-r �ia 0 a, , cg�� <br /> Contact Person: K/11 Telephone: QD ) !'444 <br /> Physical Address: P 6 a U l O S q S'71�5C-L�-dv�, (24 25 aD / <br /> E. DESCRIPTION <br /> Type Release: g �'i (�0n� �i7°, �f�irx!) C�il�C�7vP'�eAL <br /> Volume: Gf��l �'✓�v <br /> Chemicals: <br /> F. ACTION TAKEN I <br /> �',PMPM,l��'.((�r� cS=Ce%Y,,?,�'(�tQ� �/�CO�yr�✓y`�� ��'a�d7�r� <br /> C <br /> DD r, l) D D T)D <br /> C <br /> EH 22 013 (Rev. 02/90) <br />