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t i <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> -� HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG-9 <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Name: `�� c4i- Phone: (20)) 445O <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name:—yzz i ,r Q" - <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: p 1 N % —V–ae R <br /> (Best Physical Description) City or County) Circle one <br /> Date of Discharge: <br /> Date Notified: Time: i�:0'D ,oti.� <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 5fy1_+' <br /> Contact Person: J -Phone: ! <br /> Physical Address: C.A:t i 1) 177 HOZ <br /> Mailing Address: ?, p 26eK ZS5 "'l""" ' <br /> E. DESCRIPTION <br /> Type of Discharge: b.e!e\ <br /> VOlLlme: <br /> Chemicals <br /> Circumstances: <br /> F. ACTION TAKEN �"�� ,qL •S <br /> W u s a►bsa a� ^' <br /> SITE DISPOSITION 5o i ��Ga4 a <br /> lu - <br /> EH 22 013 (Rev. 08/20/98) <br />