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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHAR <br /> HEALTH & SAFETY CODE 25180 . 7 FILE COP Y <br /> A. EMERGENCY LEVEL : , II III PHS-EH LOG # l <br /> ( ircle One) <br /> Be SOURCE AQF INFORMATIO_N <br /> Name : ( J /tom es Phone : (72A" ;r <br /> Company: e �/ t �" ('� 7+ <br /> Address : .S . - o <br /> Designated Employee Name : Phone: L� <br /> Reporting Agency Name : <br /> Address : <br /> C, LOCATION AND DATE OF DISCHP�d2GE 9 r / <br /> Location: ' <br /> (Best Physical D scription) try or County) Circle One <br /> Date of Discharge : v <br /> Date Notified : ` Time : L i 00 <br /> D . RESPONSIBLE PERSON/BUSINESS <br /> Name of Business : <br /> Contact Person: Telephone: f'2!; ! S <br /> Physical Address : <br /> Mailing Address : 0 j 02k bpt� � C & <br /> E, DESCRIPTION /I <br /> Type of Discharg : �/✓ ({ � d L� <br /> Volume : / �7 <br /> Chemicals : <br /> Circumstances , <br /> el <br /> F . ACTION TAKEN <br /> rev .+ <br /> SITE STATUSiee <br /> 6 L <br /> ff <br /> EH 22 013 (Rev. 4/91 ) <br />