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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> op <br /> A. EMERGENCY LEVEL:0 II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: B/G Phone: 7� 70-ss�o <br /> Company: .4.2G a <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: 30,/ /-I-. <br /> C. LOCATION AND DATE OF DISCHARGE / <br /> Location: <br /> (Best Physical pescp'ption) (CUP or County) Circle One <br /> Date of Discharge: i/zy/gam <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 60,5-o <br /> Contact Person: '40 Telephone: (E!�9 ) 9---,Fr w? <br /> Physical Address: YS <br /> Mailing Address: S�'S x z-.4 <br /> E. DESCRIPTION <br /> Type of Discharge: v <br /> Volume: / <br /> Chemicals: 6'-4 <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE DISPOSITIO_N �_ Go wr�G s c3�- A 4. 4. <br /> H 22 013 (R .4/91) <br />