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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 /> rcle one) <br /> B. SOURCE OF INFORMATION <br /> Name: Prone: ( ) <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: FN CSO ✓. H LA 1U I A�Lh mo <br /> (Best Physical Description) (City orCounty) Circle one <br /> Date of Discharge: La qi <br /> Date Notified: 2 14 M9 Time: 17-os a m <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: LAY - 0�0 <br /> Contact Person: (Y^^ 5h d R Phone: 2 'L( <br /> Physical Address: 5 <br /> Mailing Address: FO `~ <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: uI M11,31 <br /> Chemicals: <br /> Circumstances: E r nr C)rre d a -d u-�r_l uu k L S,,0 �t 0,j-f- <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> EH 22 013 (Rev. 0$120193) <br />