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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> 1 <br /> A. EMERGENCY LEVEL: T)II III PHS-EH LOG #_ <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: i�y � L',�.�1/ — Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: L c. <br /> Reporting Agency Name: <br /> Address:_ G'h �vxJyuz c/ s'% <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: �=/�v / /'✓'• FCC--z;�:-,`?� <br /> (Best Physical Description) (City or County) Circle One <br /> Date of Discharge: <br /> Date Notified: Time:D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: L,1 '5/:,4 �o// onf�E�"�� %�a,�/ �E,�'✓rte" <br /> Contact Person: 44," Telephone: /D - 2oS-7 <br /> Physical Address: ' i oai <br /> Mailing Address: —IQo/ <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION T N �;.'o <br /> SITE DISPOSITION__ <br /> ifs /'�;?/� /OiC� ��,ALL'C✓�f' <br /> EH 22 013 (Rev.4/91) <br />