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�✓ SAN JOAQUIN COUNTY v <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 ,' <br /> A. EMERGENCY LEVEL: . I II III PHS-EH LOG # <br /> (9le One) <br /> B. SOURCE OF INFORMATION <br /> Name: Lt? - �m- n— �r i c�a .S Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name:4j �-r -�-t w Of i G S Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: V2 ,0 ,Z 's , <br /> (Best Physical Description) City r County) Circle One <br /> Date of Discharge: 1� � ��'`y( <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: ► i 'F' ' <br /> Contact Person: i Telephone: <br /> '4 <br /> Physical Address: _ <br /> Mailing Address: 53 �f f� C�h uJ-�-a cry s-�� f�°�rte- - <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN <br /> ia2 a <br /> SITE5-TATUS <br /> S411n <br /> Lc <br /> EH 22 013 (Rev-4/91) <br />