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A. <br />B. <br />SAN JOAQUIN COUNTY <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7 <br />EMERGENCY LEVEL: I 11 (111 <br />(Circle One) <br />SOURCE OF INFORMATION <br />Name: <br />Company: <br />Address: <br />Designated Employee Name: <br />Reporting Agency Name: <br />Address:3� 6 <br />PHS -EH LOG Tr <br />a <br />Phone: (_) <br />C. LOCATION ANDD TE OF DIyCHARGE <br />Location: 224 £ • f R��rto� / <br />(Best Physical Description) Cityr County) Circle One <br />Date of Discharge: Uil/,CiIlouJ� <br />Date Notified: // /i• ? Time: /7--30.0- <br />A <br />E. <br />F. <br />RESPONSIBLE <br />Name of Business: <br />PERSON/BUSINESS <br />Contact Person: _ <br />Physical Address: . <br />Mailing Address: _ <br />-e39 <br />DESCRIPTION <br />Type of Discharge: G�VVi�iV�u1�/ <br />Volume: U ZXA1QU)A1 <br />Chemicals: e5v'+60 4-/ ^1e r---c- <br />S/a 1o57r•V S'oo <br />ACTION TAKEN: <br />SITE STATUS .5166 /A/ AtWIW-It�OFV 2�4c lA' 6 �/�wy�T o•d5 �7� • <br />EH 22 013 (Rev -4/91) <br />