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u v <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:D II III <br /> PHS-EH LOG # <br /> (Circle One) <br /> 3. SOURCE OF INFORMATION Phone: X09 �'��-�`�� <br /> Name: <br /> Company <br /> � <br /> Address: 20Z Phone: *i <br /> Designated Employee Name:Reporting Agency Name: <br /> Address: 3v <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: (City o Co Circle One <br /> (Best Physical Description) <br /> Date of Discharge: n - <br /> Date Notified: <o //-,i, Time= 9- 3 ` X71 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 1-21,/,n s la. v <br /> Contact Person: L 0 L a z� L G%y z� Telephone: 7 <br /> Physical Address: - 2- '' 4 <br /> Mailing Address: <br /> DESCRIPTION <br /> Type or Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: /�-c�1 s <br /> 4tiGY CzrZ Zc a v-ec- .o <br /> L <br /> Vp <br /> F. ACTION TAI-CEN <br /> / <br /> SITE STATUS <br /> A <br /> F: 4 22 013 (Rev.4/91) <br />