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• SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARG <br /> HEALTH & SAFETY CODE 25180.7 <br /> I <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: Jerry Yoshioka Phone:-( 201 468-0335 <br /> Reporting Agency Name: Public Health Services - Environmental Health Divison <br /> Address: 304 E. Weber Ave. , Stockton, CA 95201 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: e i l5 <br /> (Best Physical Description) or County) Circle One <br /> Date of Discharge: <br /> Date Notified: ! /o S Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: �- <br /> Contact Person:_ .'.G+� cs = Telephone: CZCq3 Q F''--i Q8 r <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: Unauthorized Release discovered upon tank removal <br /> Volume: Unknown <br /> Chemicals: Cc-,,1 „-)z <br /> Circumstances: Review of results of third-party soil samplinq obtained <br /> during UST removal and subsequent laboratory analyses. <br /> F. ACTIONTAKEN_ Ur�cJer � ^ouv1� �-�� k sys - =c)��e�l <br /> a«ch�sc,c, <br /> SITE DISPOSITION_ LJS T C v)a_:-r c <br /> EH 22 013 (Rev.4/91) <br />