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r } ` <br /> SAN JOAQUIN COUNTY u <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL; 10. III PHS-EH LOG # / 5-01L <br /> / <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: � � <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: ) � �: %, <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: t3 �6A _c. &A'L -N �c'r�- / / F' o/c <br /> (Best Physical Description) (City or&utyLCircle One <br /> Date of Discharge: i �2`2�rtid-zc`Yy <br /> Date Notified: / _ — G 5 Time: / / 3 c:= <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: ; -�'�c. ?2k 7, <br /> Contact Person: Telephone: 2.!LD > ,� <br /> Physical Address:, <br /> Mailing Address: At,7 <br /> E. DESCRIPTION <br /> Type of Discharge: LL- ,,10 to,_ <br /> Volume: <br /> r <br /> Chemicals: n -► r �f' ��r � <br /> Circumstanc s: <br /> F. ACTION TAKEN <br /> %ln C i//��i.'.i�C� .��i'��� )Gi`rvt�= G>.J: 4'y► <br /> �'/\��� G% � /'1. (/ � !—' [.�r/1 � ✓G�-��/liY7it. H .LIQ �� r•: Y 1��� ..c� <br /> V j <br /> SITE STATUS <br /> EH 22 013 (Rev-4/91) <br />