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SAN JOAQULr COUNTY �1 <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25I80.r <br /> A. EMERGENCY LEVEL6I II III PHS-EH LOG on <br /> (Circle one) <br /> B. SOURCE OF INFORNLATION <br /> Name: Phone: { ) <br /> Company: <br /> Address: <br /> Designated Employer Name: Phone: <br /> Reporting Agency Name: + <br /> :address 3 s <br /> C. LOCATION AND DATE OF DISCH?►RGEE -J <br /> Location: 7(�G1 Jim ems— S <br /> (Best PhysicDescription) ctv or County) Circle one <br /> Date of Discharge: Vt x-k'- <br /> Date Notified: Tithe:D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business:fdlwg _,S&L( <br /> lilde <br /> Contact Person: ; .,/rc' anter. ., vt Phone: TY+ <br /> Physical address:<107 �_ — <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> VDlume: wtn. <br /> Chemicals: <br /> Circumstances: - ' <br /> F. ACTION TAKEN <br /> SITE DISPOSITION 2=16tcQ <br /> EH 22 0 t3 (Rev. 03120M) <br />