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ii <br /> ` (%we SAN JOAQUIN COUNTY � <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 2518t D <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> ] <br /> Original Source: 4 (�!�' ' !, / -5 Telephone: - 3`/ <br /> Reporting Agency Name: ^ JoG �,r ow? ���«- ,+� � Se�U¢� �ro <br /> n <br /> Agency Contact:�� �vror 12c�-O, Telephone: 116 8- 3' S` <br /> Address: 4/`/ S u,t.� ,E 16� Com. 5 S C. LOCATION AND DATE OF DISCHARGE <br /> Location: `rf I Or �— t--)C- <br /> (Best Physical Descriptio (City or County) <br /> Date of Discharge: <br /> Date Notified: A/ Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business �✓% "s °� � <br /> r Telephone: <br /> Contact Person: /�Ie���/ /�IGcrI�_� <br /> Physical Address: -' <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: w <br /> Chemicals: E esS ea �e�,� r ��. o✓�s <br /> F. ACTION TAKEN r <br /> AA <br /> LI <br /> ?H 22 013(Rev. 02/90) J <br />