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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE V D <br /> HEALTH & SAFETY CODE 25180.7 v <br /> A. EMERGENCY LEVEL:II III PHS-EH LOG # 7 5� _0 S / <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: .4✓ Phone: (2 ) 9 clZ'3�7� <br /> Company: S <br /> Address: <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Nam <br /> Address: y�f� r��- Sq,` J ogcPvr S-7". <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: ?� G_ GoC-- / G•Q i',c��2 o ro <br /> (Best Physical Desrript'on) mer County) Circle One <br /> Date of Discharge: / 9� <br /> Date Notified: /6 Time: o •, <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: AvG S /a— Telephone: Zep) SS Z �z <br /> Physical Address: <br /> Mailing Address: 0-• 4 33 v <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: / <br /> Chemicals: Som <br /> Circumstances: <br /> /,o• ��,eE /�r5l�A. <br /> F. ACTION TAKEN AZ- /d: s <br /> �5 G v>° it AE, <br /> SITE STATUS -7-z> <br /> EH 22 013 (Rev.4/91) <br />