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' 0 <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCH (a [Py <br /> HEALTH & SAFETY CODE 25180.7 • <br /> A. EMERGENCY LEVEL: I J II III <br /> PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: <br /> Name: <br /> Company: <br /> Address: I C � ® e 6 R ✓no CA- 95-3,�-1 - <br /> Designated Employee Name: Phone. (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 400 <5-(.0 �ti��:� P�� ��� -/ M � <br /> (Best Physical Description) ty r County) Circle One <br /> Date of Discharge: <br /> Date Notified: b 2G z (�`1� Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: R Telephone: '7y� - 9 a� <br /> Physical Address: A� CA- �Sb� <br /> Mailing Address: 36®D e S°'" 1A )11 <br /> E. DESCRIPTION <br /> Type of Discharge: 141�1'k <br /> Volume: <br /> Chemicals: ,Q <br /> Circumstances <br /> F. ;ACTION TAKEN C✓ <br /> SITE STATUS <br /> EH 22 013 (Rev-4/91) <br />