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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:r I II III ' � : 4. ����,EH LOG # <br /> (Circle One) � : ` <br /> B. SOURCE Of INFORMATION <br /> Name: Phone: 61� <br /> ' <br /> Company: +�v cz;, f- <br /> J <br /> Address: =��. G C <br /> Designated Employee Name: Phone:'L ) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location:- `' R ^ <br /> (Best Physical Description) City r County) Circle One <br /> Date of Discharge: v1 <br /> Date Notified: ib Time: <br /> L� T_ <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: J , 0 ICY <br /> Contact Person: v` t� Telephoner} <br /> Physical Address: S. ` s-% ]a J <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge; .�. <br /> Volume: <br /> Chemicals: . <br /> Circumstances: <br /> U,sT- <br /> F. ACTION TAKEN <br /> �r <br /> i <br /> SITE STATUS Cie1 vVKt i , S b C U.Gv� Eye t <br /> � 7 0�•f''�P <br /> I . int "��1 `e"' �r � . . c•-•. <br /> a v <br /> �Y+ <br /> IEH 22 013 (Rev.4/91) <br />