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0 SAN JOAQUIN COUNTY <br /> FILECOPY NOTIFICATIONLTOI HAZARDOUS SAFETY EE18DI CHARGE <br /> HEAI II DI PHS-EH LOG <br /> A. EMERGENCY LEVEL.. <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: L� <br /> Name: ' ? <br /> Company: N, uw - ^ - <br /> Address: <br /> Designated Employee Name: Phone: (� <br /> Reporting Agency Name: <br /> Address: 304 -1Eloerz Avg Ga��I�lo< , Ck ggz,2 <br /> C. LOCATION AND DATE OF DISCHARGE / <br /> Location: <br /> (Best Physic escription) ty o County) Circle One <br /> Date of Discharge' 41q Np <br /> Date Notified: Ut q la 9 Time: i zoo <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: F�2 41. <br /> Contact Person: ' Telephone: ( 423 <br /> Physical Address: 2�4 2 7 l • M E <br /> Mailing Address: z� I nI Gamma WPIC <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances 4 <br /> F. ACTION TAKEN <br /> l_ las TZF�m��- 1 <br /> SITE STATUS � e� S -I,E crss�� MIII iH AlfiEss <br /> EH 22 013 (Rev-4/91) <br />