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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: III III PHS-EH L04 #_ 4?�r -OZ 2 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (Z,,4 &�v-S� <br /> Company:__ <br /> Address: P a• r�,r 6o.36 -70 7oZ-6 o-q <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address:-- sC�;SZz/ <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 1711 <br /> (Best Physical D scri tion) (�r County) Circle One <br /> Date of Discharge: <br /> Date Notified: ?/i/�� Time: " ter-ov 9•,, <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: c, <br /> Contact Person: i3/4� z.4110A*4- Telephone: 91, 670- 5 <br /> Physical Address: �o74:0 - 60 <br /> Mailing Address: _ P c, 6c>21 /1,27-Ers14- C4 0,7oZ - 60 <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: r /* <br /> Chemicals: G <br /> Circumstances: - o <br /> F. ACTION T N A$So,e,B� S v5� G�E'T.Ai� ��✓� 9� <br /> SITE STATUS <br /> EH 22 013 (Rev.4/91) <br />