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SAN JOAQUIN 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 /> Name: Phone: (�) <br /> Company: LAL, <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: 3O LA 1CI <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: I 1 Q t , 1L <br /> (Best Physic Description) Ci or County) Circle One <br /> Date of Discharge: T1 2a <br /> Date Notified: :a I'm Time: t <br /> D. RESPONSIBLE PERS /BUSINESS <br /> Name of Business: ,r Shap <br /> Contact Person: �A Wg-� LaQvZ6 - Telephone: (Sip) LF7- 95� <br /> Physical Address: INgto Z AW- <br /> Mailing Address: R O. 574S -A+ G4 94453-7 <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: LAtzj 1Ct4ow.J <br /> Chemicals: <br /> Circumstances: C>" u,.� acs 2,,;?A rf <br /> y- 5 tic yr <br /> F. ACTION TAKEN <br /> SITE STATUS <br /> Q <br /> EH 22 013 (Rev.4/91) <br />