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SAN JOAQUIN COUNTY , <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> D <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: `7yPhone: ( ) ��-3 yt1 S <br /> Reporting Agency Name: <br /> Address: L44S A) <br /> C. LOCATION AND DATE OF DISC <br /> Location: <br /> (Best Physical Descrip 'on) (City or ounty ircle One <br /> Date of Discharge: <br /> Date Notified: ,51 Time: 3 30 em <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: U U Telepho e: <br /> Physical Address: a S0�j' <br /> Mailing Address: 5 —s <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> btA <br /> F. ACTION TAKEN Lit �� 'nom ��� v►r� �`� 7 U(S <br /> SITE STATUS <br /> EH 22 013 (Rev.4/91) <br />