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SAN JOAQUIN COUNTY <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVEL: ri j 1I III PHS -EH LOG # <br />(CIRle One) <br />B. SOURCE OF INFORMATION <br />) <br />Name: Phone:OW <br />Designated Employee Name: L& CC, Phone: (2d) q,,/, 0— 3� <br />Reporting Agency Name: <br />Address: <br />C. LOCATION AND DATE OF DI <br />Location:— -7 q 0 6dL <br />- <br />(Best Physical <br />Date of Discharge: <br />Date Notified: <br />D. RESPONSIBLE PEj, <br />Name of Business: <br />Contact Person: — <br />Physical Address: <br />Mailing Address: <br />E. DESCRIPTION <br />Type of Discharge: <br />Volume: �- A <br />Chemicals: I? a- <br />a <br />/ S/ - <br />(City or County) Circle One <br />Time: <br />WON <br />ME I Nil <br />IN 1 me -MM <br />EH 22 013 (Rev.4/91) <br />