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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III MED 'PHS-EH LOG # ��- �73 <br /> ( cle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (� <br /> Company: <br /> Address: <br /> Designated Employee Name: D 1-e Phone: �" <br /> Reporting Agency Name: (`n Fn V/r OW,r ke .0� <br /> Address: L/cIS s,?- <br /> C. <br /> eC. LOCATION AND DATE OF DISCHARG <br /> Location: �Wo0l) ����C✓Z '�d��1.0 /! I/2 / 57�'G+� <br /> (Best Physical Description) or County) Circle One <br /> Date of Discharge: CL-A Lz",n fY-r <br /> Date Notified: q-?�'--/Z Time: e <br /> D. RESPONSIBLE PERS N/ USINESS <br /> Name of Business: /i ( 2�r <br /> 7e <br /> Contact Person: /Cry Telephone: L)`i <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: 4le— <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE DISPOSITION i l i " tir to <br /> 76 <br /> EH 22 013 (Rev.4/91) <br />