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SAN JOAQUIN COUNT <br /> NOTI� . ` TION OF IIAZARDOUS WM - DISCHARGE <br /> HEALTH & SAFETY CODE 25180.,7 <br /> C(O?Yy <br /> A. EMERGENCY LEVEL6) II IIIPHS-EH LOG # y 9 D� <br /> (Circle One) <br /> B. SOURCE Or INFORMATION <br /> Original Source: (n 5 Telephone: c( /1S ) 5 cf ��YUy <br /> 'Se'rV/C�s <br /> Reporting Agency Name: 1 o(a-Qv rll Cy v rt;i <br /> Agency !!)) <br /> g cY Contact: 1�4v�p r- K� -f Telephone: <br /> Address: <br /> � o c. ✓1 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: -I <br /> `� 30 cl �r c/� <br /> (Best Physical Description)— (City or County) <br /> Date of Discharge: <br /> Date Notified: �- �?5- ss7 Time: <br /> D. RESPONSIBLE PERSON BUSINESS <br /> Name of Business n ( S�n s <br /> Contact Person: ��«s Telephone: <br /> Physical Address: 3^"/S <br /> E. DESCRIPTION <br /> Type Release: C>r 0 vi d r►),, i T;$' <br /> Volume: <br /> Chemicals: ���•� _`��r' �o �u�r�, ,rY/f,,� <br /> F. ACTICON TAKEN/ <br /> Oze "/,lI'LL 4Or>/fiii/� <br /> . 6 -2 �c.� rim� fi Y1d� <br /> zh4104 1119-7/-- <br /> .. f vf� fvr• _�7l' <br /> EH 22 013 (Rev. 02/90) <br />