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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEOircle <br /> II III <br /> -EH LOG 4 5 _ <br /> one) <br /> B. SOURCE OF INFORMATION <br /> Name: /_jj ( - Phone: (?O` ) <br /> Company: Y <br /> Address: <br /> Designated Employee Name: Phone: �� 53' ' 4 3 3.1 <br /> Reporting Agency Name: J 2 r <br /> Address: �� <br /> C. LOCATION AND DATE OF DISCHARGE 6�iKO-A <br /> Location: <br /> 2 O a �c�e wC4 <br /> (Best Physical Descri tion) n , City r County) Circle one <br /> Date of Discharge: t,) 7y �'" <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: CAP, � Do ,V` A G110 <br /> Contact Person: /� Phone: — <br /> Physical Address: `a`Z� /l�Pr D t S a /\j <br /> Mailing Address: <br /> f <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: Li <br /> le�� rnror <br /> Chemicals: �--_� <br /> Circumstances: <br /> F. <br /> '' <br /> SITE DISPOSate NL <br /> �.✓ <br /> EH 22 013 (Rev. 08/20/98) <br />