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SAN JOAQUIN COUNTY • <br /> NOTIFICATION OF HAZARDOUS `HASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 - <br /> A. EMERGENCY LEVEL: it III PHS-EH LOG # <br /> ( ircle One) <br /> B. SOURCE OF INFORMATION Phone: <br /> Name: �0 y0�"�6D 9 <br /> T �i/ /g D /1 / <br /> Company: <br /> Address: � 0 �X (003 ' sla Cf1 90�oZ-dOaB <br /> Designated Employee Name: Phone. (___) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DIS HARG / <br /> Location: 1441 �- <br /> rCounty) Circle One <br /> (Best Physical Description) <br /> Date of Discharge: q-( -q 3 <br /> Date Notified: -/ F:9 3 Time: /0 '0047Y, <br /> D. RESPONSIBLE PERSON BUSINESS 2/ <br /> Name of Business: Telephone: (� 9U3- OzE36 <br /> Contact Person: 9 ZD <br /> Physical Address: <br /> Mailing Address: d . �e o. D 0 Z <br /> E. DESCRIPTION <br /> .Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances. <br /> F. ACTION TAKEN <br /> /l <br /> w <br /> S E DISPOSITION 0 5i <br /> AI <br /> a� GvK-GtJ G <br /> EH 22 013 (Rev-4/91) <br />