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SAN JOAQUIN COUNTY , <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE " <br /> HEALTH &'SAFETY CODE 25150.7-_ <br /> ikpl <br /> � <br /> A. EMERGENCY LEVEL: CI) Ii III ypF'S-EH LOG #9C>2 . /cZ2— <br /> (Circle <br /> One) .. . <br /> B. SOURCE OF iNFORMAT ON <br /> Name: }...ZV-r o r Phone: C2&) Q3I �SSd <br /> Company: • v�.x Y <br /> Address: �u��T <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Description). :E . : • City r,Cogr y) 'Circle One . <br /> Date of Discharge: fi <br /> Date Notified: & Time: /4a. <br /> D. RESPONSIBLE PERSON/BUSINESSAl , <br /> Name of Business: <br /> Contact Person: Telephone: (oi 5 3 S5 <br /> Physical Address: 5a5 93.x3z) <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: _ <br /> Chemicals: <br /> Circumstances: E <br /> F. ACTION TAKEN —r3 <br /> SITE DISPOSITION• f <br /> EH 22 013 (Rev.4/91) r <br />