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SAN 10AQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL I II� PHS-EH LOG # <br /> 'rcle One) <br /> B. SOURCE OF INFORMATION <br /> Original Source: �T,n,� ,-��,o�� (,'1,�/� ,?f=TeIephone: <br /> Reporting Agency Name: <br /> Agency Contact: 4:l Z OU Telephone: (,09 ) <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: his - n,�_J l '��' CQ _ <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business <br /> Contact Person: ���,�/ ��,� Telephone: <br /> Physical Address: <br /> E. DESCRIPTION <br /> Type Release: ����,�/f�'r•rE�/ <br /> Volume: <br /> Chemicals: /12,'�i�� <br /> F. ACTION TAKEN <br /> ? -� /Sl/+ ✓J /iC� rtv.Pp �.,^ �7 � Sa,, le- <br /> ,-i- 1,2 <br /> � -?z/ <br /> EH 22 013 (Rev. 02/90) <br />