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3 <br />C <br />SAN JOAQUIN COUNTY <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7 <br />EMERGENCY LEVEL: I II III PHS -EH LOG <br />(Circle One) <br />SOURCE OF INFORMATION <br />Name: <br />Phone: (____) <br />Company: <br />Address: Phone: <br />Designated Employee Name: <br />Reporting Agency Name: <br />Address: S: <br />LOCATION AND DATE OF DISCHARGE <br />Location: <br />(Best Physical Description) <br />Date of Discharge: — — <br />Date Notified:— - 9 Time: r 0 'Do <br />i r County) Circle One <br />D. RESPONSIBLE PERSON/BUSINESS <br />Name of Business: <br />t,,,�� �- ��� ��-� Telephone. (46Contact Person: <br />Physical Address: . ......�"' ` <br />tilailing Address: <br />E. DESCRIPTION <br />Type of Discharge: <br />Volume: <br />Chemicals: _ <br />Circumstances: <br />Q <br />F. ACTION TAKEN <br />EH 222 013 (Rev.4/ 91) <br />