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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25,180.7 rr . <br /> A. EMERGENCY LEVEL®rcle <br /> I III PHS-EH LOG #One) <br /> B. SOURCE F INFORM ION „ <br /> Name: �� a �i Phone: dol`6 <br /> Company: <br /> Address: <br /> Designated Employee Name: if Phone: (�) <br /> a Reporting Agency Name: it i <br /> Address: <br /> C. LOCATION AND DATE <br /> OF DISCHARGE <br /> E <br /> Location: =!'..iGUL� /1I:Z�3�•O��;� 02�. / <br /> (Best Physical escription) ��. �; (mit or County) Circle One <br /> Date of Discharge: <br /> Date Notified: Time: ii. <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: If <br /> o <br /> li Contact Person: atAA-- IVIC4- 11 Telephone: <br /> Physical Address: _ Z9 Slc�c- �� �i•v s�^ � y G� �'A 9�T/� <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: ' <br /> Volume: 'I <br /> Chemicals: 0T G� E�7�cEu ,cav a s P <br /> Circumstances. G �vses <br /> F. ACTION TAKEN <br /> } <br /> i <br /> if <br /> SITE STATUS <br /> r <br /> EH 22 013 (Rev.4/91) <br />