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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISOiARGE C <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVE III III PHS-EH LOG # <br /> CH <br /> One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (� <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: _ �- <br /> Address: 6_ J J,> <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Description) Ci or County) Carle One <br /> Date of Discharge: IC,wnm . <br /> Date Notified: 4 -/6 —9 Time: S:av pr-1 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: 12& i1Z ._>.,1d klTelephone: L� <br /> Physical Address: s<sc /n n.1 <br /> Mailing Address: —T <br /> E. DESCRIPTION nn <br /> Type of Discharge: <br /> Volume: w <br /> Chemicals: s�P 6p.a <br /> Circumstances: <br /> ACTION TAKEN <br /> SITE DISPOSITION �r tw J4, r <br /> 3 ? 22 013 (Rev.4/91) <br />