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I if <br /> SAN JOAQUIN COUNTYo �D <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGar( � <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL II III PHS-EH LOG # �� <br /> ircle One) <br /> 1' <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: m Q 5- v ejL&TF Phone: 4160-Q33 <br /> Reporting Agency Name: <br /> Address:_ Al -YVDGz � cam, Gd�� G9- SZ�Z <br /> C. LOCATION AND DATE OF DI HARGE <br /> Location: <br /> (Best Physical Description) City r County) Circle One <br /> Date of Discharge: Lc1')Lr&'Vj1n <br /> Date Notified: -3- Time: 2=o D <br /> D. RESPONSIBLE PERSON/ USINESS { <br /> Name of Business: l <br /> Contact Person: _ ���n GvK� t� _ Telephone: <br /> Physical Address_ y25 N, G 1 TZ'ad� &M -3)-4- f6Le-i-m Cj+ <br /> Mailing Address: SQ-- <br /> E. DESCRIPTION lI <br /> Type of Discharge: V S <br /> Volume: C1n'1lGnaw�'� <br /> Chemicals: <br /> Circumstances:_ UST r" _ <br /> F. ACTION,TAKEN <br /> Y 41I <br /> 62 <br /> SITE STATUS 77 <br /> rOL <br /> v W <br /> EH 22 013 (Rev.4/91) <br />