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, <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> • HEALTH & SAFETY CODE 25180.7 <br /> l <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # 916' / <br /> O I <br /> ( ' de One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: L� <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 2"14- <br /> (Best Physical Des ption) 'ty Countyl Circle One <br /> Date of Discharge: <br /> Date Notified: I Time: _�efl✓n <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 'T7�s-S4i, <br /> Contact Person: �-.c- <br /> Physical <br /> c Telephone: <br /> Physical Address: a;:2ct 4j . � Z:►,..E � �t �7G� <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: ��So <br /> Volume: - k A r,�k&X.QCSj <br /> Chemicals: <br /> Circumstances: r,:� e-�j�aez44--nQ �.,(� �„i G�'rt r, ,jS4:E4,:�_� <br /> F. ACTION TAKEN <br /> SITE STATUS —T"Cn,E Gt -o�wz; c�;k �t 2r1a.�v k, <br /> EH 22 013 (Rev-4/91) <br />