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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE O �� <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL II III PHS-EH LOG # �� _` Z-1 <br /> / <br /> ( .ircle One) <br /> B. SOURCE OF INFORMATION Phone: L� <br /> Name: <br /> Company: <br /> Address: ^g <br /> Phone: <br /> Designated Employee Name: 1) <br /> Reporting Agency Name: a MD <br /> Address: 0 <br /> C. LOCATION ANDDATEOF DISCHARGE / <br /> Location: Ci or�) Circle <br /> (Best Physical Descri ) <br /> Date of Discharge: r <br /> Date Notified: (a Time: G O <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: <br /> Physical Address: o a- <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> 1 2 <br /> Cir umstances: q 2E <br /> � <br /> F. ACTION TAKEN -Y a <br /> i.L-A,O l\ enn, ,lei r <br /> SITE STATUS T `� <br /> C <br /> EH 22 013 (Rev.4/91) <br />