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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVE, 1I III PHS-EH LOG# !lJ Jl l <br /> ircle one) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: ( ) <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: o 5 71 r-./, __ ----- � <br /> (Best Physical Description) uy r County) Circle one <br /> Date of Discharge: <br /> Date Notified: Time: 62 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: G-(—L,- <br /> Contact <br /> k,-Contact Person: , c.t� 1ti; Phone: — <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: Lt W&J�Lmj <br /> Chemicals:^_ _ lAJ <br /> Circumstances: <br /> F. ACTION TAKEN g ; <br /> SITE DISPOSITION nti S, e/y <br /> EH 22 013 (Rev. 08/20/98) <br />