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0 • <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGED <br /> HEALTH & SAFETY CODE 25180.7 O <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <br /> ( ircle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (_) <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: �) _ <br /> Reporting Agency Name: eA- <br /> Address:Zc4 b A ohm 3 pr S c+4- og-W <br /> ll <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: /?_ It) _ Ax w ,&r L,, <br /> (Best Physical Description) ((�or County) Circle One <br /> Date of Discharge: n . <br /> Date Notified: 6- N -5 6 Time: Z 3 d PM <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: (jl4m ,".4-r- �vL <br /> Contact Person: Telephone: (zy2D sV3 - 33 <br /> Physical Address: .S ZS S z 46 <br /> Mailing Address: PO v�. <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: Ukwtir� <br /> Chemicals: _�r�al,�..-e- <br /> Circumstances: Y),m ,~ u chn-r .nu_ <br /> F. ACTION TAKEN � ir..t �o i& 4 0P <br /> SITE STATUS nm/ �miA] .. <br /> EH 22 013 (Rev.4/91) <br />