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SAN JOAQUIN COUNTY `Ole <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 C(OPY <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG # �� _ �oC <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name:, c,--- r Phone: ,Q- 3Y-,� <br /> Company: <br /> Address: <br /> Designated Employee Name: Z e-74-/ f�`Cc- .E 0 i u 4-S Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OFISGC�HARGE S,� S Y-0 G <br /> Location: 6'10 / <br /> (Best Physical Descripti n) �or County) Circle One <br /> Date of Discharge: J OZy7'� <br /> Date Notified: Z— l CP Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: L� <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: LGn <br /> Volume: _ <br /> Chemicals: <br /> Circumstances: ` <br /> F. A ION TAKEN CI'i <br /> SITE STATUS <br /> �-7 <br /> EH 22 013 (Rev-4/91) <br />