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1� <br /> 0- 4 - <br /> 0 <br /> i� Q ,D <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION or- HAZARDOUS 'WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180. <br /> A. EMERGENCY LEVEL II III PHS-EH LOG # os <br /> (Circle One) <br /> B. SOURCE OF INFORMATION � <br /> n <br /> Original Source:S4 44-P- Telephone <br /> u <br />. Reporting Agency Name; A :0. <br /> Agency Contact _ Telephone: ( <br /> Addresst •� <br /> C LOCATION AND DATE OF DISCHARGE <br /> Location: ,�.� I1 �q I a <br /> _L <br /> (hest Phys al Description) (City or aunty) <br /> c <br /> Date of Discharge. UofA M612, <br /> , <br /> Date Notified. 3115 Time: <br /> D. RESPONSIBLE PERSONIBUSINESS <br /> 9 <br /> I. Name of Business wtn-�004-, <br /> Contact Person:` Telephone. Ctfjg ) c� 35 —3F 3 3 <br /> Physical Address: 5-qeO.tn- Q1- Gtv <br /> E. DESCRIPTION <br /> Tye Re ease. tom.. COVI- � <br /> Vola ai. h � <br /> Chemicals: �� <br /> F ACTION TAKEN <br /> , . t <br /> 1�;>• t J <br />• tXXih • <br /> EH 22 03 (Rev. 7/89) r. 1 <br />