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SAN JOAQUIN COUNTY O Py <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARG <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: PI III PHS-EH LOG # �d —0a <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: /GG 01 � 2� Phone: (ZI-4 <br /> Company: ,Wco ��ovcrS Co <br /> Address: a �X 60 � „s. �� 17a 7c? <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Descn tion) r County) Circle One <br /> Date of Discharge: <br /> Date Notified: �,�i19� Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: <br /> Physical Address: �L� <br /> Mailing Address: �iD7oL - 6� <br /> E. DESCRIPTION I <br /> Type of Discharge: <br /> Volume: ��a• <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION T N <br /> SITE STATUS <br /> EH 22 013 (Rev-4/91) <br />