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SAN JOAQULN COUNTY FILE COPY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE ----- _ <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVELPircle <br /> II III PHS-EH LOG 9 of — 056 <br /> one) <br /> B. SOURCE OF INFORMATION <br /> Name: 1 Phone: (7m) <br /> Company: S Co <br /> Address: <br /> Designated Employee Name: 5 Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 1!41 &1 A COG <br /> (Best Physical Description) ity r County) Circle one <br /> Date of Discharge: n Time: . 31 <br /> Date Notified: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: Phone: <br /> Contact Person: 1! <br /> Phvsica! Address: c� <br /> Mailing Address: 5 '� <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: _ a <br /> Circumstances'. Caj <br /> F. ACTION TAKEN <br /> SITE DISPOSITION f <br /> EH 22 013 (Rev. 08120198) <br />