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rA SAN JOAQUIN COUNTY '^' <br /> NOTIFICATION OF IIAIARDOUS WASTE DISCHARGE <br /> 14EALT1-1 & SAF M- CODE 2S18d.7,' <br /> 10 A. EMERGENCY L.$VEL� PIIS-EI-1 LOG'# <br /> (Circle One) <br /> B. SOURCE OF INFORMATION _ I <br /> Original Source: -50 i � lTelephone: <br /> Reporting Agency Name: d ,fir► T,J7S" s <br /> Agency ContactP�.✓Ie/ ~ .Telephone: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE ` <br /> Location: <br /> (Best Physical Description (Cit or County) i <br /> Date of Discharge: v ., <br /> Date Notified: ae d C] (� <br /> Time: " <br /> D: RESPONSIBLE PERS N/BUSIN -S5 <br /> • Name of Business rA <br /> Contact Person: G <br /> Telephone: (_ ) <br /> Physical Address: <br /> �. DESCRIPTION <br /> 7pe Release: / - <br /> Volume: /7 <br /> Chemicals: -7 - <br /> air <br /> F. ACTION TAKEN f <br /> n D <br /> oe <br /> of <br /> d <br /> elc <br /> EI-1 22 013 (Rev. 02/90) <br />