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• SAN JOAQUIN COUNTY i <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7 �1 <br />A. EMERGENCY LEVEL: I II III PHS -EH LOG # — <br />(Circle One) <br />B. SOURCE OF INFORMATION <br />Name:%� C&ti LAf / Phone: <br />Company: <br />Address: ?-U, SZn <br />Designated Employee Na e ,{� Phone: (�) <br />Reporting Agency Name: <br />Address: <br />C. LOCATION AND DATE <br />(Best Physical <br />Date of Discharge�: �S <br />Date Notified: � <br />D. RESPONSIBLE <br />Name of Busing <br />Contact Person <br />Physical Addres <br />Mailing Addres, <br />E. DESCRIPTION <br />Type of Dische <br />Volume: <br />Chemicals: S <br />F. ACTION <br />(City <br />Circle One <br />F1 <br />us <br />EH 22 013 (Rev.4/91) <br />