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r <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: III III PHS-EH LOG # <br /> ( ircle One) <br /> B. SOURCE OF INFORMATION <br /> Name: (kka�-w.� ?•!3 <br /> Phone: ( ) VV <br /> " X002 <br /> Company: o - <br /> Address: c 6to-, f <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE S to <br /> Location: 2 S 2-b / <br /> (Best Physical Description (City or County) Circle One <br /> Date of Discharge: 2 I 14, q <br /> Date Notified• IllbTqr Time: <br /> D. RESPONSIBLE PERS N/BUS NESS <br /> Name of Business. <br /> Contact Person: Telephone: (9 <br /> Physical Address: '( fo �uw <br /> Mailing Address: <br /> E. DESCRIPTION , <br /> Type of Discharge: ,. -... <br /> Volume: D 36 _ <br /> Chemicals: , H2,50v C <br /> Circumstances: <br /> F. ACTION TAKEN ;A-Q B- <br /> c <br /> SITE STATUS <br /> Gc/ <br /> � � I <br /> EH 221 (Rev-4/91) <br /> 0 3 ( 4/9 ) <br />