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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 # <br /> (Circle One) <br /> 3. SOURCE OF INFORMATION <br /> Name: l W1 1 �..,- Phone: <br /> Company: — <br /> Address: - <br /> Designated Employee Name: c` i Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: a I I /U, (,(� / Sf0 C— <br /> (Best Physical Description) City r County) Circle One <br /> Date of Discharge: <br /> Date Notified: d G y-- Time: <br /> �. RESPONSIBLE PERSON/BUSINES� _ <br /> Name of Business: y��ytp y�I - I ( I <br /> Contact Person. 0yuTelephone: <br /> Physical Address p ) `r — `F <br /> Mailing Address: i� �� f1 �n L <br /> _. DESCRIPTION <br /> Type of Discharge: , G(/�1Ct LhJ <br /> Volume: rye U � � <br /> Chemicals <br /> Circumstances: SS S r t <br /> ACTION TAKEN <br /> ax- Pcc�P <br /> - o <br /> D / 0 12 IL4a - <br /> SITE fVSPO51,17O w <br /> L <br /> .122 013 (Rev.4/91) <br />