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0 <br /> SAN JOAQUIN COUNTY • <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCYLEVEL: III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE F INFOMs <br /> ON <br /> Name: I GA. Phone: <br /> Company: - d <br /> Address: <br /> Designated Employee Name. 5 Phone: (� <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 5?09 1, <br /> (Best Physic Description) (City o Coun Circle One <br /> Date of Discharge: <br /> Date Notified: jt-3>D-t)2 Time: <br /> D. RESPONSIBLE PERSON/BUSIN SS <br /> Name of Business: <br /> Contact Person: I U Telephone: ( ) <br /> Physical Address: <br /> Mailing Address: 3O L 32Z3& <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: 4l. <br /> Chemicals: aAd <br /> Circumstance •_ _l,t x.( Y� <br /> F. ACTION TAKEN �q <br /> SITE DISPOSI ION AA <br /> EH 22 013 (Rev.4/91) <br />