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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL II III PHS-EH LOG <br /> cle One) <br /> B. SOURCE OF INF0 MATION � <br /> Name: GG l �� �G'/a_ Phon A�j <br /> `j�O <br /> Company: <br /> Address: 7 -f it <br /> Designated Employee Name: Phone: ,r3�! <br /> Reporting Agency Name: <br /> Address: zo r f S's z�J <br /> C. LOCATION AND DATE OF WSCHARC4E <br /> Location: t� 7 1'- /9ir <br /> (Best Physical Descn 'on) ( ounty) Circle One <br /> Date of Discharge: } <br /> Date Notified: Time:��� Z� <br /> D. RESPONSIBLE PERSOBUSIME <br /> Name of Business: /P niilj <br /> Contact Person: 9 Tel p one: r_W J- 7.n <br /> Physical Address: - �¢ Kw <br /> Mailing Address: 111:6 <br /> E. DESCRIPTION <br /> Type of Discharge: GJ� <br /> Volume: <br /> Chemicals• D r C <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE STATUS d <br /> EH 22 013 (Rev.4/91) <br />