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0 <br />SAN JOAQUIN COUNTY 0 <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVELoircle <br />II III <br />One) <br />Al <br />SOURCE OF INFORMATION <br />Name: <br />Company: <br />Address:_ <br />Designated Employee Name: <br />Reporting Agency Name:; <br />Address: _a,�2L c - r,,ic�w <br />PHS -EH LOG # <br />q(-� - / o3 <br />Phone:1� 9 -7j 4f7-3 <br />Phone: <br />C LOCATION D DATE OF DISCHARGE�� 1 �� <br />Location: o• / <br />(Best Physi al Desc ption)// (City or un ' cle One <br />Date of Discharge: / •Z-/S^�i -b <br />Date Notified: I Z — r -� Time: D <br />D. RESPONSIBLE PERSON/BUSINESS <br />Name of Business: 106. f <br />Contact Person: 4 - <br />Physical Address: 1 <br />Mailing Address: 2& �4= J <br />E. DESCRIPTION <br />Type of Discharge: <br />Volume: <br />Chemicals: <br />Circumstances: '�� fxutss <br />F. <br />Telephone: (0 , <br />SITE STATUS c-02 6 <br />EH 22 013 (Rev.4/91) <br />