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SAN JOAQUIN COUNTY <br /> NOTIFICATION Or I-IAZARDOUS WASTE DISCHARGE <br /> T-IEALTH & SAFE'T'Y CODE 2S 180.j <br /> V l� <br /> A. EMERGENCY LEVEL:0 II III PHS-EI LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Original Source: ��,�,�n - Tele hone: <br /> Reporting Agency Name: <br /> Agency Contact: Telephone: (2q ) q 6 8-3 c/ <br /> Address: N <br /> C. LOCATION AND DATE OF DISCHARGIr <br /> Location: Peld <br /> 5 -7� s S <br /> al IHSS/ U <br /> est PhysicDescri��ityilpt,on) (City o County) <br /> Date of Discharge: _ � n D2 <br /> Date Notified: —) Time: <br /> D. RESPONSIBLY PERSON/BUSINESS <br /> Name of Business u <br /> LL <br /> Contact Person: Tele hone: L f5 -7 ) - �y0 d <br /> Physical Address: 0 P, 1 C \ <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: <br /> Chemicals: <br /> F• ACTION TAKEN " <br /> EI T 22 013 (Rev. 02/90) <br />