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0 <br />[a <br />N <br />SAN JOAQUIN COUNTY <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />-.2 <br />HEALTH & SAFETY CODE 25180.7 <br />11 <br />EMERGENCY LEVEL: III 0 <br />(Circle One) <br />SOURCE OF INFORMATION <br />Name: /+ I U. Ie,- <br />Company: <br />Address: 19go /V <br />Designated Employee Name: <br />Reporting Agency Name: <br />Address: zl-e-IS /K. <br />LOCATION AND DATE OF DISCHAI <br />Location: z.1z fk;2! z"Cze, / <br />(Best Physical Description) <br />Date of Discharge: z2 --/G <br />Date Notified: — Xik <br />Ice, - <br />.GE <br />PHS -EH LOG #—C? <br />i, <br />Phone: ((�) <br />7�112 45, . <br />Phone: (n�:51 <br />am <br />(City or County) Circle One <br />D RESPONSIBLE PERSON/BUSINE <br />Name of Business: <br />Contact Person: Telephone: (�). -9 j <br />Physical Address: /Z fo JOS <br />Mailing Address: <br />W <br />F. <br />Type of Discharge: Z'�vel 5,0v <br />Volume: <br />Chemical <br />Circumst; <br />ACTION TAKEN <br />EH 22 013 (Rev.4/91) <br />