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Q <br /> SAN JOA UIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 = , <br /> U <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <br /> ircle One) <br /> B. SOURCE OF INF R ION <br /> Original Source: 41 , I`Gt pegS C�►� Telephoner) <br /> Reporting Agency Name: <br /> Agency Contact: -L -C, Telephone: `f(v - <br /> Address:---P, a-D 4 <br /> C. LOCATION AND DATE OF DISCHA,R a <br /> GE <br /> Location: y A T) /q p r R <br /> :39 / <br /> (Best Physical Description) (City or Co nty) <br /> ' <br /> Date of Discharge: f f / <br /> Date Notified: / / - f o Time: 3 % v O <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business 0 <br /> Contact Person: Teleph ne: (_ ) <br /> Physical Address: Q � '� �Q C <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: <br /> Chemicals: <br /> F. ACTION TAKEN <br /> LA b � s <br /> -r C = 0. � - <br /> �� <br /> EH 22 013 (Rev. 02/90) <br />