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4 <br /> SAN JOAQUIN COUNTY : <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> (r <br /> A. EMERGENCY LEVE4 11 I11 PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION I <br /> Original Source: rw Qom,5ait4+S Telephone: 3s- <br /> Reporting <br /> SReporting Agency Name: a <br /> Agency Contact: /1C a,,,"u Telephone: (o- �U <br /> Address: �1 . OQ 9 &4"A' C)Og E <br /> 9� <br /> C. LOCATION AND DATE OF DISCHARGE + s <br /> .i <br /> Location: /(JO (,t?e / �ha ' <br /> (Best Physical Descrip ion) (City or C nty) <br /> Date of Discharge: <br /> D <br /> Date Notified:' Time: a , <br /> D. RESPONSIBLE PERSO BUSINESS J n <br /> Name of Business Q-c-L�c� C✓ -4_J p <br /> Contact Person: SSS Telephone: r.l LL <br /> Physical Address: r 0 a <br /> E. DESCRIPTION , <br /> Type Release: MZ -2-.� � � w� �` 4,LaL <br /> Volume: 6,1,k IZ4, <br /> Chemicals: 4--r # <br /> F. ACTION TN <br /> i <br /> EH 22 03 (Rev. 7/89) <br /> *I fl 13Sz 0(0 W Al>e A-T- -n <br /> .; <br />