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ty SAN JOAQUIN COUNTY , <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHAR <br /> HEALTH & SAFETY CODE 25180. 7 k <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # � - U <br /> (Circle One) <br /> B. SOURCE OF INFORMATIS2I� <br /> Name: r i cq c S Phone: <br /> Company: <br /> Address : <br /> Designated Employee Name: J Phone: c&") �// � - �"(� . <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AN DATE DATE OF DISC GE <br /> Loca[ion:?TL7 <br /> (Best Physical Description) (City or County) Circle One <br /> Date of Discharge: mac/ f <br /> Notified: - Time: <br /> 11 ud ave " <br /> Date � - � 9 �f � <br /> D . RESPONSIBLE PERSON/BUSINESS �� - . _ <br /> a <br /> i Name of Business: � ") n �= - r e ' <br /> Contact Person: , Telephone: 2�b ) Z/ & <br /> Physical Address: <br /> Mailing Address : / Q 'iX777C74 '77-7 J,;z - G0 � <br /> E. DESCRIPTION 7r/K <br /> Type of Discharge: �/ fl - �� � <br /> Volume: le 4 v <br /> Chemicals : <br /> Circumstances : , <br /> Ad Y-LZIty"o <br /> p <br /> F. ACTIO TAKEN <br /> S Dvv <br /> a— <br /> LfI <br /> SITE 1}F P ITION c %er <br /> EH 22 013 (Rev.4/91 ) <br />