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/+ `V <br /> SAN JOAQUIN COUNTY; <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 251 <br /> A. EMERGENCY LEVEL: I II II PHS-EH LOG <br /> (Circle One) i <br /> B. SOURCE 0 INF <br /> RMATION <br /> Name: " RJ2 °lam avr� �Q � O'�eoc.L p <br /> Company: a Phone: <br /> Address: 8'0-5 171, 1s•• 1-/•zz <br /> Designated Employee Name: f Phone: (_) <br /> Reporting Agency Name: <br /> Address: I. <br /> t <br /> C. LOCATION AND DATE OF�DIISSC-HAI E <br /> Location: X3,73 <br /> (Best Physical Description) City r County) Circle One <br /> Date of Discharge: -X� <br /> Date Notified: /Z-/(o-Q/ Time:._ I' <br /> D. RESPONSIBLE PERSON/ USINESS /1 i <br /> Name of Business: <br /> Contact Person: ��.. /3 Telephone: - 35 <br /> Physical Address: ;1-3¢� <br /> Mailing Address: f <br /> If' <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN � u eat �,. C'•A P / <br /> til _ <br /> SITE DISPOSITIO i <br /> Ila <br /> iKBu} 0- a- <br /> 6 <br /> EH 22 013 (Rev.4/91) <br /> li <br />