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,l <br /> SAN JOA UIN COUNTY LJ <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE`"✓ <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL•• II II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> � '�y�� ��� ��3 7 <br /> Name: Phone: tau A <br /> Company: � <br /> Address: /10 O SIR 0 <br /> Designated Employee Name: o S Phone: g <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE S �i � <br /> Location: l 00(� s4 S T L' G� cvti, / 7(-fC-/ <br /> (Best Physical Description) �7�r County) Circle One <br /> Date of Discharge: �./yI.C¢C� <br /> Date Notified: t— // 9 Time: O42 <br /> D. RESPONSIBLE PERSON/BUSI ESS <br /> Name of Business: - ` G <br /> Contact Person: Telepho : — 3 7 <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION ��� S,, <br /> Type of Discharge: ZW <br /> Volume: G <br /> Chemicals: <br /> Circumstances: ,c,c 1 <br /> F. A ON TAKEN <br /> 2 c �- <br /> SITE STATUS <br /> -7-- <br /> a <br /> EH 22 013 (Rev.4/91) <br />