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= T <br /> SAN jOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WANE DISCHARGE F <br /> HEALTH & SAFETY CODE 25180.7 <br /> r <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE O NFO TION tr&, -3 v W a <br /> Name: 501 /P5 Phone: (2c&) <br /> Company: e5� <br /> Address: it7f0 er Gin <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: te G ,-4 <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Description) City r County) Circle One <br /> Date of Discharge: �ZaLa <br /> Date Notified: Time <br /> r <br /> D. RESPONSIBLE PERSON/BUSINESS e, <br /> Name of Business: _ Cle, y <br /> Contact Person: Telep one: tiz-2) 9,vy- 7 ' <br /> Physical Address: _ ya N l6yr� G9 IS.r�c2,Z�._- <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: &54 <br /> Chemicals: <br /> Circumstances: _ "k <br /> i <br /> F. ACTION TAKEN_ �- LM-4 F'1 � <br /> SITE DISPOSITION _ P ms's <br /> I <br /> f <br /> l- I <br /> Y I <br /> EH 22 013 (Rev.4/91) <br />