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Q SAN JOAQUiN COUNTY f <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 , <br /> Y s <br /> A. EMERGENCY LEVEIII III PHS=EH LOG # <br /> ircle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: L� <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: zc-;,) 3 <br /> Reporting Agency Name: CO- <br /> Address:�3 ,mss- �•�6� / ,r� � �,._ �_ <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location:lr�LZaL4±-.� e.-�0_d -S' <br /> (Best Physical Description) Gi r County) Circle One <br /> Date of Discharge: ( m4m-oz <br /> Date Notified: - Time: OU F <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person:- '6 ZZ10 Telephone: � ,470=Zaj <br /> Physical Address: <br /> Mailing Address: ' .On. "cam= c�3 4 g 2 7-0 <br /> E. DESCRIPTION n *" <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: 6awn fiM2 <br /> Circumstances <br /> 1-j f Ili <br /> F. ACTION TAKEN <br /> `SITE DISPOSITION'(7)�irc mac.--,r..� ;1-p r� - <br /> EH 22 013 (Rev.4/91) M <br />