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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: 0 II III PHS-EH LOG m 9:6- <br /> (Circle <br /> One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company: , <br /> Address: 6 2-1-6 C2LQ,, <br /> CA- <br /> Designated Employee N Phone: �) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DAT- OF ,DISCHARGE <br /> Location � � z 6�1�w L a <br /> (Best Physical scription) City or County) Circle One <br /> Date of Discharge: <br /> Date Notified: OL2 Time: <br /> D. RESPONSIBLE PERSONAIBUSI SS <br /> Name of Business: ��/ c i„�, <br /> Contact Person: Telephone: <br /> Phvsical Address: <br /> Mailing Address: . D. ?-o <br /> E. DESCRIPTION <br /> Type of Discharge: 1L4� <br /> Volume: <br /> Chemicals: <br /> Circumstances: W zl'� <br /> D2 <br /> F. ACTION TAKEN /? a 11dz& �� ��� / 5 /1-e/�dL�C <br /> w ( • <br /> SITE STATUS <br /> EH 22 013 (Rev-4/91) <br />