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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVELG II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Original Source: S Telephone: (Y/S5 <br /> �0 <br /> Reporting Agency Name: �7 <br /> /4 <br /> Agency Contact: � Telephone: 0u q ) _e <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 8TO V i G+rL-. Req <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: I c— / <br /> Date Notified: �n_ Time: <br /> D. RESPONSIBLE PERSON USINESS <br /> Name of Business 6 ; <br /> Contact Person: _L. 1., Telephone: <br /> Physical Address: O a C a <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: <br /> Chemicals: <br /> F. ACTION TAKEN <br /> 4�-3. <br /> W S <br /> s <br /> �-- <br /> EH 22 03 (Rev. 7/89)' ,t <br />