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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: /j?,�clir9 C���Is Phone: zo6 —03 <br /> Company: n u <br /> Address: o <br /> Designated Employee Name: Phone: 4;6,=©-K2'27 <br /> Reporting Agency Name• <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 461, C / <br /> (Best Physical De ption) Ci r County) Circle One <br /> Date of Discharge: �o <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: e os <br /> Contact Person: Telephone: )���/�= X7364 <br /> Physical Address: 3 l o O <br /> Mailing Address: 1-*2O f��x, <br /> E. DESCRIPTION `�� <br /> Type of Discharge- ��`7 <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN S <br /> SITE STATUS <br /> o d " <br /> EH 22 013 (Rev.4/91) <br />