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SAN JOAQUIN COUNTY PY NOTIFICATION OF HAZARDOUS WASTE DISCHAR O <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: III PHS-EH LOG # O <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: 6�4 Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address:---5-,W <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: qoa s. =- <br /> (Best Physicalescriptiof) ( r County) Circle One <br /> Date of Discharge: ��14 0t..11 <br /> Date Notified: r= 27� Time: 2:00,0 4. <br /> D. RESPONSIBLE PERSON/BUSINES,S <br /> Name of Business: _ c7 <br /> Contact Person: - Telephone: <br /> Physical Address: moo s. cY1 e D, Loo r 9s�slo <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: 0.,9 s _ <br /> Circumstances: &Oe�- - S <br /> F. ACTION TAKEN_ 72.1 <br /> =5Ov �i rS l,,•� ,O,o,2.Tei <br /> SITE DISPOSITION <br /> Grp —b �. EL6aS J.c <br /> EH 22 013 (Rev.4/91) <br />