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SAN JOAQUIN COUNTY A <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: oI II III PHS-EH LOG #_ <br /> (Circle One) <br /> B. SOURCE OF INFORMATION ``// <br /> Name: Phone: T' -?,6 6o <br /> Company: <br /> Address: 3a <br /> Designated Employee Name: a-a _ f G Phone: 0") ) ,6. 2,6 <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DSC ARGE <br /> Location: /S al- <br /> (Best PhysicalDe�ion Ci or County) Circle One <br /> Date of Discharge: "` <br /> Date Notified: 2--7 Zoa Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: �c� Telephone: (_) <br /> Physical Address: <br /> Mailing Address: /06 cel` �l5 /62-0 u. 1L. 60015 <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: e C' ozehtd <br /> Circumstanc s: <br /> F. ACTION TAKEN_ •-/k .� a� /� ��c d <br /> SITE DISPOSITION <br /> f E' <br /> EH 22 013 (Rev.4/91) <br />