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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL III [IIQEDIEDD <br /> G # <br /> ircle One) <br /> B. SOURCE OF INFOI N <br /> Name: Phone: <br /> Company' <br /> Address: <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISC G <br /> Location:&2/ <br /> (Best Physical Description) City r County) Circle One <br /> Date of Discharge: <br /> Date Notified: P,?t l L9R�f Time: q 3oc< <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: t��C{ e IBJrQ �O <br /> Contact Person: ab -JCL'A Telggphone: �2M 3 — I <br /> Physical Address: 32-01 l J -1 by i Vo li n h fR��l�� UVl N S 5 3 5 <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: k- <br /> Chemicals: A`l <br /> Circumstances: YwC 0,(OaV�P— <br /> F. ACTION TAKEN GtIrX <br /> SITE STATUS Sri a G /Yl St &e <br /> EH 22 013 (Rev.4/91) <br />