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r <br /> SAN JOAQUIN COUN 1`Y <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180 7 � LJ <br /> A EMERGENCY LEVEL I II III PHS-EH LOG # �C� U <br /> { ircle One) <br /> B SOURCE OF INFORMATION <br /> P <br /> Name V ohRa R 115 vPhone ( ) 5r Z- O�Od <br /> ' Company G L - <br /> Address 1 (VLO ou� C' 53 - <br /> ' Designated Employee Name Phone- <br /> Reporting Agency Name <br /> Address• <br /> 'C LOCATION AND DATF OF DISC GE <br /> Location L40r'1, . -e. <br /> ' (Best Physical Description) ( i r County) Circle One <br /> Date of Discharge lC�v1�`rn <br /> Date Notified _ ( � <br /> o -2�--,ty Time <br /> ' ON <br /> D RESPONSIBLE PERS BUSINESS/ <br /> Name of Business- V <br /> ` Contact Person e Telephone QD '46,&_031 <br /> Physical Address U 1r <br /> ' Mailing Address <br /> E DESCRIPTION <br /> Type of Discharge <br /> ' Volume <br /> Chemicals <br /> Circumstances �Y d C vl fs <br /> r <br /> ' ACTION TAKEN ` <br /> tSITE STATUS <br /> f <br /> ,u1 - <br /> ' EF1 22 013 (Rev 4/91) <br /> i <br />