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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 C (D) <br /> A. EMERGENCY LEVEL:�II III PHS-EH LOG ��� <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: <br /> Name: L.� <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: EL93 Z/68- 3%S"p <br /> - Reporting Agency Name: <br /> Address: 30 y <br /> C. LOCATION AND DATE OF DISC�R GE <br /> Location: 3 3 0 1164e <br /> (Best hysical Description (City or � Circle One <br /> Date of Discharge: 1�keI � <br /> Date Notified: 9/30 Z'� Time: <br /> D. RESPONSIBLE PERSO�T/BUSINESS ��' � <br /> Name of Business: �rh P,-161rir <br /> �/u6 - <br /> Contact Person: " ' fiy , Telephone: L3 -7 <br /> Physical Address: S /� P S G �''' °1 )j /17 <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: Gh ���✓✓ <br /> Chemicals: <br /> Circumstanc s: G�Sr' r'� ' �G rr r / �' �✓ ,¢i ' r <br /> F. ACTION TAKEN 1-117L' <br /> S T TUS -o s- i ,'�l �' / r d Ji r ry e 17/ <br /> EH 22 013 (Rev-4/91) <br />