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� '±± SAN J'OAQUIN COUNTY <br /> NOTIFICA�N OF HAZARDOUS WASTE QCHARGE <br /> HEALTH & SAFETY COBE 25180.7 <br /> 44 ak ' <br /> I <br /> A. EMERGENCY LEVEL. <br /> I II III PHS-EH LOG # O U ea"5 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Original Source:„ GV GM ' t t~�d�C� d,_. Telephone: <br /> Reporting Agency Name: S/" <br /> f� S •A:•r`r� !� <br /> F <br /> Agency Contac�,__l?1} -L + � Telephone: znr' <br /> r <br /> I <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: /D y L,? //li <br /> (Best Physical Description) ( ity or County) 1 <br /> Date of Discharge% <br /> Date Notified: 7- Z 2 9 C) Time: 3 'yo <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business <br /> Contact Person: Ibmae f Telephone: LI 7 ' <br /> Physical Address: 1kx_ I v71 �)Ii.;• <br /> E. DESCRIPTION <br /> Type Release: <br /> ..(' <br /> Volume: <br /> Chemicals: .-�- <br /> F. ACTION TAKEN <br /> wx TV, <br /> jf -L- 4LIzz ' _4z" <br /> /22 <br /> F <br /> EH 22 013 Rev. 02/rA6 <br /> (C I <br /> [F)'y <br /> (DO, <br />