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D� <br /> QSAN JOAQUIN COUNTY <br /> D NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVE I) II III •EH LOG� <br /> ircle one) <br /> B. SOURCE OF INFORMATION <br /> Name: A - l2 c� Phone: (�65) yb?-1D06 <br /> Company: <br /> Address: qQQ <br /> Designated Employee Name: Phone. <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: ' ' / <br /> (Best Physical Description) ( r County) Circle one <br /> Date of Dischar e: <br /> e Time: <br /> Date Notified: 20 ZeDO <br /> D. RESPONSIBLE PERSONBUSINESS <br /> Name of Business:�l�/ <br /> Contact Person:'( < < Phone 5 3 l S$S <br /> Phvsical Address: <br /> Mailing Address: '? 7114 <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: telt- <br /> Chemicals: Q <br /> Circumstanc �^ <br /> F. ACTION TAKEN <br /> ure%t�v a��0 f r <br /> Ax <br /> c • <br /> u/ <br /> 12MSITE DISPOSITION <br /> EH 22 013 (Rev.08/20/98) <br />