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SAN JOAQUIN COUNTY <br />N077FICA"FION OF HAZARDOUS WASTE DISMIRGE <br />HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVEL: Iii III PHS; 1! EH LOG m 1 CJ <br />(Circle One) <br />3. SOURCE OF INFORMATION <br />Name:` 1 L± L_Gc1 f` C, G S �# Phone: <br />Company: ... j� <br />Address: <br />Designated Employee Nance: ; c, 4 S'. _ Phone: GL01) � <br />Reporting Agency Name: .. <br />Address- <br />C. LOCATION AND DATE OF DISCHARGE <br />Location:_ -1 a2f,-L4_ <br />(Best Physical Description) <br />Q§5or County) Circle One <br />Date of Discharge: it <br />Date Notified: -1, Time: <br />D. RESPONSIBLE P <br />Name of Busines <br />Contact Person: <br />Physical Address <br />Mailing Address: <br />S. <br />DESCRIPTION <br />Type or Discharge: <br />Volume: <br />Chemicals: KL U <br />EH 22 013 (Rev.4/9 1 ) <br />L <br />