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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL. I II III PIIS-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: U <br /> Company: S <br /> Address: <br /> Designared Employee Name: Phone: �) <br /> Reporting Agency Name.- <br /> Address: <br /> ame.Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location:1�,Q S. K\x-- �C„�., / <br /> (Best Physical Description) r County) Circle One <br /> Dare of Discharge: _ '"I13�R4, <br /> Dare Notified: T=e: to.oa f <br /> D. RESPONSIBLE PER.SON/BUS11,TESS <br /> Name of Business: <br /> Contact Person: -�'o�- cazE2 tc-� Telephone: <br /> Physical Address: lam 4tg,5a;,,� Z,:a 0-L T-\Y— C. v-.V, <br /> Ma_i.:ring Address: <br /> E. DESCRL07TON <br /> Type of Discharge: ice. <br /> volume: <br /> Cheanicals: <br /> Circ=stances- <br /> F. ACTION TA1MN i A2 <br /> SITE DISPOSITION : 1P,—r- <br /> EH 22 013 (Rev-4/91) <br />