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A. <br />C. <br />101 <br />E <br />F. <br />SAN JOAQUIN COUNTY <br />NOTIFICATION OF HAZARDOUS WASTE DISCHAR - � <br />HEALTH & SAFETY CODE 25180.72 <br />EMERGENCY LEVEL: II III PHS -EH LOG # qA'q <br />( =le One) <br />SOURCE OF INFORMATION <br />Name: 5 7-V IV <br />Company: <br />Address: <br />Designated Employee Name: <br />Reporting Agency Name: <br />Address: <br />LOCATION AND DATE OF DISCHAR( <br />Location: / Zi�)O 6 Vos6W-5i% <br />(Best Physical Description) <br />Date of Discharge: uJAl <br />Date Notified: -- g— <br />10 <br />M <br />Phone:/0 2-77- 2-31 <br />• , - <br />City r County) Circle One <br />RESPONSIBLE PERSON/BUSINESS <br />Name of Business: Ac-sco °te l 23 <br />Contact Person:Es �° Telephone: (Zr <br />Physical Address: /700 9--`L <br />Mailing Address: ?A(90 C'A:±�- <br />DESCRIPTION <br />Type of Discharge: G -f`- <br />EH 22 013 (Rev -4/91) <br />