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SAN JOAQ <br /> UIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISC _ <br /> HEALTH & SAFETY CODE 25180.7 _ ✓� <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # 10 <br /> ( ircle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (2!!!) `l8 "'/00 Z <br /> Company: <br /> Address: ct <br /> esi ated Employee Phone: (_) <br /> D gn ee Name:p y <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: S 2,(0a / ��o -t <br /> (Best Physical Description (City or County) Circle One <br /> Date of Discharge: <br /> Date Notified: Time. <br /> D. RESPONSIBLE PERS N/BUS NESS <br /> Name of Business: 0 S CX61,1 u'W-eA, 0 . <br /> Contact Person: Telephone: (�� 6 ' 3 8� S Z <br /> Physical Address: f0 "" <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: .-. <br /> Volume: 0 <br /> Chemicals:V IH2,sou <br /> Circumstances: <br /> F. ACTION TAKEN11 <br /> /Lay.•v1te. /'� Qi�c <br /> SITE STATUS <br /> w <br /> EH 22 013 (Rev.4/91) <br />