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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DIH�4RGE <br /> HEALTH & SAFETY CODE 25180.7h- <br /> PHS-EH LOG # <br /> �3 <br /> A. EMERGENCY LEVEL: IT III <br /> . (Circle One) <br /> B. SOURCE OF INFORMATION Telephone: <br /> Original Source: Rtc <br /> Reporting Agency Name: Telephone: <br /> Agency Contact: _'C', L <br /> �v� <br /> Address: �u5 <br /> C. LOCA'T'ION DATE OF�Rio DISCHARGE <br /> / STt�G/<Tb1� <br /> Location: 3� ( Ci or County) <br /> (Best Physical Description) (City <br /> " Date of Discharge: �' � w <br /> Time: 4q: 3o a <br /> Date Notified: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business 4c{g- rrD f <br /> Contact Person: Telephone: ( z ) <br /> Physical Address: 5- onQdd <br /> E. DESCRIPTION <br /> Type Release: �uTNrR� <br /> Volume: vwril <br /> Chemicals: G�4G� � JO,QOdUGT <br /> F. ACTION TAKEN - <br /> Soc� <br /> �zC <br /> OF Ca1�lT"Q�`'r/TCT/Dl� S 1QF_A <br /> EH 22 013 (Rev. 02/90) <br />