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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # �� —0 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: �0)2cr,j - <br /> Name: 196 4 <br /> Company: -7— <br /> Address: <br /> Designated Employee Name: Phone: [_) <br /> Reporting Agency Name: <br /> Address: *104 S �,ZEIOaQ- <br /> C. LOCATION AND DATE OF DESCHARG1E <br /> Location: z�! . dg <br /> (Best Physical Dg cngon) <br /> (City o Dunt/ rcle One <br /> Date of Discharge: (. t 2 g <br /> Date Notified: to 4 R Time: 10h h <br /> D. RESPONSIBLE PERSOWBUSINIESS <br /> Name of Business: <br /> Contact Persson: Telephone: (-Z,:L�60 5 Z.4 -4b5 <br /> Physical Address: ° <br /> Mailing Address: LZ a2"4:5 5 3 <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Che:-meals. ( �E <br /> Circumstances: <br /> F. ACTION TAKEN uc2-E <br /> SITE STATUS n, ;-r a <br /> EH 22 013 (Rev.4/91) <br />