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a SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEI II III PHS-EH LOG# OO O <br /> 1rcle one) <br /> B. SOURCE OF INFORMATION <br /> Name: Yyl i L'\6tZI L14e-rdCkel z _Phone: ( ) <br /> Company: M-1C(obar-ck-tq L- <br /> Address: 0 lo�31 CVl a d��-� S 7 <br /> Phone: <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> 1�^J ° /� � <br /> Location: `..� \ -� i r County) Circle one <br /> (Best Physical Description) <br /> Date of Discharge: <br /> Time: <br /> Date Notified: -,-t e --� <br /> D. RESPONSIBLE PERSONIBUSINESS <br /> Name of Business: S L <br /> Contact Person: Phone: <br /> Physical Address <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: _ <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN r.-u l-c.e_- I A/YJ""'- 7" n= — V\ <br /> rt_D <br /> SITE DISPOSITION <br /> 1 <br /> EH 22 013 (Rev. 08/20/98) <br />