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,a. <br /> O <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE i� <br /> HEALTH & SAFETY CODE 25180.7 ��~ � �` � � <br /> A. EMERGENCY LEVEL: II II- III PHS-EH LOG # <br /> Circle One <br /> B. SOURCE OF INFORMATION <br /> Name• t�m <br /> r Phone: 3 <br /> Company: WeLG1 . <br /> Address: <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location:L, JEt, b,(� <br /> (Best Physical Description) (City o oun ) Circle One <br /> Date of Discharge: rj),,0 <br /> Date Notified: _ ( 1 1 0� ire= '°Q <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: ct m ig n <br /> Contact Person: Telephone: Q12�) <br /> Physical Address: I '-OC&Ld 9l vd 5{ocrE � cl 2 <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: CAP V - c�ar1 <br /> Volume: ���✓L6w`� <br /> Chemicals: <br /> Circumstances: AlecaA ' - f <br /> j E bnt`�JQ <br /> F. ACTIONTAKEN <br /> ✓�vyt. �/ S-k Q <br /> SITE DISPOSITION ; ✓A� <br /> h SS LLST' w c 1, <br /> L-:�a 2 <br /> EH 22 013 (Rev.4/9 ' <br />