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ri <br /> SAN JOAOUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180,7 <br /> A• EMERGENCY LEVEL: II III <br /> (Circle One) PHS-EH LOC r2, <br /> B. SOURCE OF INFORMATION <br /> Original Source: .GALS <br /> .. Telephone: ( yams) 7 '8 3 - C <br /> Reporting Agency Name: <br /> Agency Contact: `[�,� 1� <br /> Telephone: <br /> Address: 9 <br /> C• LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> c <br /> (Best Physical escription) (City or County) <br /> Date of Discharge: <br /> Date Notified: 5 Time,• 3d ,,.,., <br /> D. RESPONSIBLE PERSON/BUSINESS I <br /> 1 <br /> Name of Business k 10 A <br /> Contact Person: _6 ��C�= Tc Telephone: Z <br /> Physical Address: ' �Z gig <br /> r <br /> — ,e � <br /> E. DESCRIPTION ti M <br /> Type Release: f o• .- <br /> TYP <br /> f <br /> Volume: w <br /> Chemicals: <br /> F. ACTION TAKEN <br /> I <br /> U, <br /> EH 22 03 (Rev. 7189) <br /> tl <br />