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SAN J'OAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Original Source: &�/��,,.,�,�,Fj � 40,-f' Telephone: <br /> Reporting Agency Name: <br /> Agency Contact � w- mfr Cih <br /> Telephone: <br /> Address: eq <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Description) (City or Cou„iy)- <br /> Date of Discharge: � �- <br /> Date Notified: 7 � Time: 116"1250 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business "4-' 4- E <br /> Contact Person: (!�O�wn, Telephone: <br /> Physical Address: ,j (4,1LW <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: d�✓� <br /> Chemicals: <br /> F. ACTION TAKEN <br /> �un �d N� LPS G I7'8�l• ✓r/�rri Si .�.YS�"�,✓7L <br /> r <br /> �l <br /> EH 22 03 (Rev. 7/89) <br />