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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 . <br /> A. EMERGENCY LEVEL:01 III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: 4-4AX Lelo-�• p1trikz. Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: 74 VA 3 YY 2- <br /> Reporting A encyName: .� �o. -1-t� <br /> Address: v o <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: /Nl A-4 .�'''� � � / 5-FoC�2 <br /> (Best Physical Description) V (City Coun Circle One <br /> Date of Discharge: S"id, z <br /> Date Notified: S' g Time: 00 A, <br /> D. RESPONSIBLE PERSON/BUSINFSS <br /> Name of Business: ZOik . <br /> Contact Person: Telephone: <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: Lv <br /> Circumstances': -'g-0,- cru <br /> F. ACTION TAKEN ,dLP� aezzul- 0a <br /> SITE DISPOSITION w <br /> �_ a �� �- w • .-r�.c•�'1 .rte,. :.�.. <br /> EH 22 013 (Rev.4/91) <br />