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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> 111f <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG # cI �ti7� <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: l �.'f i c�r i s c;A� Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: �, c. <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: l & q AW . _ <br /> (Best Physical Description) (City oun Circle One <br /> Date of Discharge: — L— q.3 <br /> Date Notified: La—j! — 93 Time: <br /> D. RESPONSIBLE PERSON/B�SINESS <br /> Name of Business: t w _ t <br /> Contact Person: Telephone: (Jn 3) <br /> Physical Address: _ <br /> Mailing Address: S a�m—t— <br /> E. DESCRIPTION <br /> Type of Discharge: S <br /> Volume: <br /> Chemicals: ' <br /> Circumstances: S v c <br /> F. ACTION TAKEN <br /> 77 • t ih2� a G <br /> o� <br /> l Y Y <br /> SITE DISPOSITION <br /> w r i !,' f 1✓ <br /> r- A C <br /> 1, <br /> EH 22 013 (Rev.4/91) <br />