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SAN JOAQUIN COUNTY [PY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE C(D <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: 01 III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (_) <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Na}ne: <br /> Address: --F,;34Qu,n1 <br /> C. LOCATION AND DATE OF�DISCHARGE <br /> Location: moo s• � �' / Gor��� <br /> (Best Physical qesSriptio ) (J�r County) Circle One <br /> Date of Discharge: <br /> Date Notified: Time: rr vo Q•ti <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: c r Telephone: 5S7I <br /> Physical Address: d4ni <br /> Mailing Address: 525 9323 o <br /> E. DESCRIPTION I, <br /> Type of Discharge: l/iY�y v z <br /> Volume: <br /> Chemicals: <br /> Circumstances: rr 6-. i 2 <br /> b rL Co� <br /> F. ACTION TAKEN <br /> SITE STATUS 3,E- <br /> EH <br /> 3,EEH 22 013 (Rev.4/91) <br />