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SAN JOAQUIN COUNT k7l <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEII III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Original Source: c r/ /N4- Telephone: (,2 ) <br /> Reporting Agency Name: <br /> Agency Contact: Ctior� /41.'It— Telephone: Qo�7 <br /> Address: o- S�1_,,kid� �U <br /> C LOCATION AND DATE OF DISCHARGE <br /> Location: Z7 �,,,f, n <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: <br /> Date Notified: G /g/fp Time: SIAM <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business Fr'o <br /> Contact Person: / <br /> �- ���^ Telephone: (20g <br /> Physical Address: S' <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: <br /> Chemicals: n <br /> R ACTION TAKEN <br /> .142 <br /> �✓�'C1f 7t �iC�T �7` I' � IN�•,� � <br /> EH 22 03 (Rev. 7/89)' <br />