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• SAN JOAQUIN COUNTY • <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARI L E COPY <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: ( I !II III <br /> PHS-EH LOG # <br /> ( rcle One) <br /> B. SOURCE OF INFORMATION <br /> Name: —r x Phone: <br /> Company: <br /> Address: 17 ✓Ylo C7k- 9c,3,� <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHAR�G_En <br /> Location: x(00 S�0 zjkA " �� L � / M <br /> (Best Physical Description) iry r County) Circle One <br /> Date of Discharge: <br /> Date Notified: bRC Z� lcf°I1� Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: R,i Telephone: ( 1 9 -a(� <br /> Physical Address: z SGS. <br /> Mailing Address: X690 t^ <br /> E. DESCRIPTION <br /> Type of Discharge: I Al� <br /> Volume: <br /> Chemicals: P <br /> AD r <br /> Circumstances: <br /> F. ACTION TAKEN C✓ <br /> dwMley/ <br /> s es <br /> III a <br /> h aac <br /> SITE STATUS <br /> W <br /> C/rVY1 <br /> EH 22 013 (Rev-4/91) <br />