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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE r <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL• I II III PHS-EH LOG # O <br /> ( ircle One) <br /> B. SOURCE OF INFORMATION <br /> Name: `�'nt Atm Phone: /L3 <br /> Company: <br /> Address: 3 i 4 &ecx- , <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: q l3 ry\t .Q1.e.14-z / <br /> (Best Physical Description) City r Co ) Circle One <br /> Date of Discharge: <br /> Date Notified: -� I 'GIG `_ Time: c4 (,6 0 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 0 P w - <br /> Contact Person: Telephone: <br /> Physical Address: S cnt 0 <br /> Mailing Address: 61 <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: I <br /> Chemicals:- - C,)) <br /> Circumstances: <br /> n <br /> F. ACTION TAKEN � �- "A � <br /> SITE STATUS <br /> V <br /> EH 22 013 (Rev-4/91) <br />