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I-41w, SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG# <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (Ul <br /> Company: <br /> Address: l ctg tAf-e.aa- <br /> Designated Employee Name: Phone: Z Q 9 Y6 8 � Y�7 <br /> Reporting Agency Name: s a-a o i�� Ge F Aa lir ex 0--4-` <br /> Address: 3 64 L. �'�`�--� , f Tc�C C 0'r- <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: S J ' aa� <br /> (Best Physical Descript on) (City o ounty) Circle one <br /> Date of Discharge: <br /> Date Notified: o Time: 3 .4 <br /> D. RESPONSIBLE PERSONBUSINESS <br /> Name of Business: <br /> Contact Person: Phone: - a <br /> Physical Address: IS 12. 1 A e 4 <br /> Mailing Address: S A n^, t <br /> E. DESCRIPTION <br /> Type of Discharge: A-rS E <br /> Volume: A&11� <br /> Chemicals: r%-7C 01, f- <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE DISPOSITION t <br /> • <br /> EH 22 013 (Rev. 08/20/98) <br />