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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> cc <br /> A. EMERGENCY LEVEIO II III PHS-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (_) <br /> Company: <br /> Address: <br /> Designated Employee Name: S'Tc l/F,J J' „� Phone: <br /> Reporting Agency Name: <br /> Address: 3141 if. G(/� �'f �� � � �f�:� �f� J!. O/ <br /> C. LOCATION AND DATE OF DISC GE L <br /> Location: A 0D �- / n/ r %� S4- / `� <br /> (Best Physical Des 'ption) C' r County) Circle One <br /> Date of Discharge: h <br /> Date Notified: 3 zza Time: <br /> D. RESPONSIBLE PERSON/BUSI ESS <br /> Name of Business: //,n 0a _� <br /> Contact Person: Telephone: <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: A a <br /> Volume: C'r /CJ's -y <br /> Chemicals: -r6,4- , PCE, <br /> Cir;umstances: <br /> ftp 6 U o &i C /b / 4: Lk 7 1-, - <br /> ACTION TAKEN 4P <br /> SITE STATUS /I<Z i <br /> H 22 013 (Rev.4/91) <br />