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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> G <br /> A. EMERGENCY LEVEL: 6) II III PHS-EH LOG # / <br /> (Circle One) <br /> B. SOURC�jjOF INFORM ION _ <br /> Name: / Phone: <br /> Company: � g 4 <br /> Address: /Y50 <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DAT OF DISCHARGE <br /> Location: o� / �Ckyx <br /> (Best Physical Description) Ci r County) Circle One <br /> Date of Discharge: <br /> Date Notified:Notified: OCT a , /1}S Time: e0e) - <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: Ae,7 - 7y <br /> Contact Person: _2j7Z _ elephone: /� - <br /> Physical Address: <br /> Mailing Address: ,e e Z3 <br /> E. DESCRIPTION <br /> Type of Discharge: -�x�-� ^� <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN /- <br /> U•S. T.�� <br /> e <br /> SITE STATUS <br /> l— <br /> -d <br /> EH 22 013 (Rev.4/91) <br />