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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE C(Dpy <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # D ��- <br /> ( 'rcle One) <br /> B. SOURCE OF INFORMATION <br /> Name: ti oxi Phone: X10- 5 g <br /> Company' r 0 6144-ems Cz <br /> Address: P.Q . goy Loo 3B � <br /> An e5l, - C,4q 024 ("9 <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DI CHARGE <br /> Location: �0 60ani" <br /> (Best Physical Description) ity r County) Circle One <br /> Date of Discharge: <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: - ' Tele phone: (9 ) <br /> Physical Address g 1W Gena WiLeBY1� i — <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Dischar e: lkv <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. A IO TAKEN <br /> SITE STATUS �1a`/ -�-r <br /> r <br /> EH 22 013 (Rev.4/91) <br />