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SAN JOAQUIN COUNTY <br /> C' <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I I II III PHS-EH LOG # <br /> (&cle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: yC-�7 S Y Y Z <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE qF DISCHARGE <br /> Location: 92? t.+-! LIZ 14J / 5n <br /> (Best Physical Description) City or County) Circle One <br /> Date of Discharge: <br /> Date Notified: =,Z Time: 11-,10,q. "I <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: (3� n # !� 1�� Telephone: O <br /> Physical Address: Sb t� L' �✓ So ;:k <br /> Mailing Address: A.C• tSOX S-004 CA- qq! '—e Ogv y <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> volume: <br /> Chemicals: <br /> Circumstancew.. -,"D <br /> F. ACTION TAKEN <br /> SITE STATUS <br /> EH 22 013 (Rev-4/91) <br />