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SAN JOAQUIN COUNTY J <br /> NOTIFICATION OF HAZARDOUS WASTE DISC <br /> HEALTH & SAFETY CODE 25180.7 E <br /> (C(DD <br /> A. EMERGENCY LEVELI II III <br /> PHS-EH LOG # <br /> ircle One) <br /> is IIr <br /> B. SOURCE OF INFORMATION I <br /> Name: rA M-0 e-- <br /> Company: <br /> ✓Company: . Phone: <br /> Address: tis �i r <br /> Designated Employee Name: S <br /> y r <br /> Reporting Agency Name: .5.,�.,.� �:� � Phone: q6 3� . <br /> Address: Ll 4 S. <br /> i+ <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: p C) — k ? <br /> (Best Physical Description) ` <br /> Date of Discharge: {City or oun Circle One } <br /> ' <br /> Date Notified: f to 9 Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: el hone: L� <br /> Physical Address: p p 0 v <br /> Mailing Address: ,r -5(,-7 c�C.+ , <br /> Rsaa3 <br /> E. DESCRIPTION <br /> Type of Discharge: LcJ�(C <br /> Volume: ,�, �. <br /> Chemicals: , <br /> Circumstances: <br /> f. <br /> F. ACTION TAKEN } <br /> A. <br /> C <br /> E� <br /> SITE STATUS ' . YN-) <br /> U <br /> EH 22 013 (Rev.4/91) <br /> i <br />