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0-�"__ <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHAR <br /> HEALTH & SAFETY CODE 25180.7 O <br /> A. X EMERGENCY LEVEL: _ <br /> � II III PHS-EH LOG # <br /> (Circle One) ! <br /> B. SOURCE OF INFORMATION <br /> Original Source: <br /> - Telephone: ( -- D5r <br /> Reporting Agency Name: <br /> Agency Contact: <br /> +dries Telephone: <br /> Address: 0 & <br /> C. LOCATION AND DATE OF DISCHARGE <br /> '. Location: ( ' / <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: <br /> Date Notified: <br /> Time: 'DIJ ►'� <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business <br /> 4T Contact Person: Telephone: ( � — <br /> Physical Address: 3 LJc35r' �prtir�t4 <br /> -37r, GAd TZ&r CA . ysiz4. <br /> E. DESCRIPTION <br /> Type Release: U.4 re <br /> Volume: <br /> Chemicals: A_-S_r90LWQA <br /> F. ACTION TAKEN <br /> UA ooC10 <br /> 1 r S <br /> C +�c�" I•nGC.� <br /> EH 22-03 (Rev. 7/89)' <br /> i <br />