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SAN JOAQ UIN COUNTY G <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> Q <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (2LG) <br /> Company: <br /> Address: 3 i <br /> Designated Employee Name: Jerry Yoshioka Phone: C_LOJ 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(,!y -mak+o. <br /> (Best Physical Description) or County) Circle One <br /> Date of Discharge: y nknc<< <br /> Date Notified: /i :3/ 45- Time: 3OC: h <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 7-8 L. IA C r L<C---t- <br /> Contact Person: Telephone: ZO(l) <br /> Physical Address: S0,5- <br /> Mailing <br /> pisMailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: Unauthorized Release discovered upon tank removal <br /> Volume: Unknown <br /> Chemicals: C <br /> Circumstances: Review of results of third-party soil sampling obtained <br /> during UST removal and subsequent laboratory analyses. <br /> F. ACTION TAKEN (..Inger clrbuoas14z-, C n <br /> U <br /> SITE DISPOSITION cJST n�,c�u�ncnc�'� <br /> EH 22 013 (Rev.4/91) <br />