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SAN JOAQUIN COUNTY 0 <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />(opy HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVEL: I <br />II III PHS -EH LOG # <br />(Circle One) <br />C. <br />SOURCE OF INFORMATION <br />Name: Phone: (_) <br />Company: G -}-*V, <br />Address: <br />Designated Employee Name: Phone: �) <br />Reporting Agency Name: <br />Address: SOCA- '5. <br />LOCATION AND DATE OF DISCHARGE <br />Location: 9,5S C....' �.I cakk4 �}- / <br />(Best Physical Description) <br />Date of Discharge: <br />Date Notified: Time: t4.-. meN* rn <br />City County) Circle One <br />D. RESPONSIBLE PERSON/BUSINESS <br />Name of Business: S�' -t-4--"aE: <br />Contact Person: CJ^ LAC� � ��,.. Telephone: ("O qi, -2 (6-11 <br />Physical Address: <br />Mailing Address: CL MO <br />E <br />F <br />DESCRIPTION <br />Type of Dischz <br />Volume: <br />Chemicals: <br />• ■ _ <br />EH 22 013 (Rev.4/91) <br />