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.r SAN JOAQUIN COUNTY �► <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III G # �( c `-' U01.le One) <br /> B. SOURCE OF T*'FORMAT ON <br /> Name:_C `! �oD �T Phone: c <br /> Company: <br /> Address. `{ r10 zlf e ' ve. O O <br /> Designated Employee Name: 6 <br /> Reporting Agency Name: o�C — 5i v.✓ �/ <br /> Address: .S� a/o •' c C� �Zo <br /> C. LOCATION AND DA_�/CE F D CHARG <br /> Location: ROD 111-4 <br /> (Best Physical Description) Ci r County) Circle One <br /> Date of Discharge: c oov <br /> Date Notified: 2S/- Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 4 0 4, <br /> Contact Person: oh- ro Telephone: (Zoo <br /> Physical Address: �a D <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Disch ge: < <br /> Volume: w• <br /> Chemicals: c c <br /> Circ tances: r o C ✓e <br /> oe o <br /> F. ACTPN TAKEN a Dx o r?� <br /> vera � <br /> SIT ISPOSITION <br /> EH 22 013 (Rev.4/91) <br />