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i! <br /> SAN JOAQUIN COUNTY , <br /> ` NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 2511'80.7 !'i 1 <br /> A. EMERGENCY LEVEL: <br /> I II III C(DPHS-EH LOG # � <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: L <br /> Company: f <br /> Address: r <br /> I ' <br /> Designated Employee Name: Phone: (7� 344! <br /> Reporting Agency Name: S - ( j! <br /> Address: (�0 g Oda �g �� G44 SZo( —O 3 <br /> C. LOCATION AND ATE OF DISCS E <br /> Location: LD CQ <br /> (Best Physical Description) !` <br /> .I�. (Ci am(County) ircle One <br /> Date of Discharge: I attjU14DA <br /> Date Notified: le- Lg- Time: obi O&Q,HV, <br /> ir <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: t I <br /> Contact Person: Telephone: <br /> Physical Address: 13q et ti . A Ae C.a S.Z�fO <br /> Mailing Address: ' <br /> E. DESCRIPTION <br /> Type of Discharge: k�1 <br /> Volume: tA A n <br /> Chemicals: n <br /> Circumstances: JAS <br /> ti--�'1 <br /> F. ACTION TAKEN L,lr9-"�s C.la� �E n pI.A�� �.O _ (�C1C.rejw. _LLQ-L <br /> ;. <br /> SITE STATUS U' M`rr7e, Q <br /> rlR-h Sa. U M i 4CA 4- <br /> r <br /> o n S Qeu <br /> bra s ke `7 <br /> EH 22 013 (Rev.4/91) <br />