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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> r CC\ . ell J, }_ 2 <br /> A. EMERGENCY LEVEL•plircle <br /> II III PHS-EH LOG # O�/ <br /> ( One) <br /> B. SOURCE Og INFOU4ATION <br /> Name: <br /> Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION 3 DATE OFF, DISCHARGE <br /> / S TD/✓ <br /> Location: F. <br /> (Best Physical Description) (City r County) Circle One <br /> N <br /> Date of Discharge: ti0 u//J <br /> Date Notified: ''20-4 7 Time:— <br /> D. RESPONSIBLE PERSO /BUSINESS <br /> Name of Business: 1654JIV607W <br /> Contact Person: j^�`� Telephone: (_) <br /> Physical Address Av -2254L <br /> Mailing Address: YqO, <br /> E. DESCRIPTION �G/{�� -sl•u> <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: `— <br /> Circumstances: <br /> GO P <br /> F. ACTION TAKEN44 <br /> yb <br /> Z <br /> SITE STATUS f <br /> C <br /> EH 22 013 (Rev.4/91) <br />