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SAN JOAQUIN COUNTY _` <br /> NOTIFI' TION OF HAZARDOUS WASTE DC�.iARGE <br /> F.ALTH & SAFETY CODE 251 <br /> . 80.7. <br /> I <br /> A. EMERGENCY LEVE ii III ` <br /> z C .' PHS-EH'LOG # <br /> Ircle One) , k ---- <br /> B. SOURCE OF IrjFqRM.ATION <br /> Name: <br /> Company: <br /> ,�{� Phone: <br /> Address: �# <br /> Designated Employee Name: i3Z <br /> Reporting Agency Name: i Phone: , 3 <br /> Address: <br /> 3 <br /> F C. LOCATION D DATE OF DISCHARGE <br /> Location: n Q, <br /> (Best Physical Description) (City �Coun�) ircle One <br /> Date of Discharge: v�� <br /> Date Notified• 2 Time: D .100 <br /> I� <br /> D. RESPONSIBLE PERSO BUSINESS <br /> Name of Business: r <br /> Contact Person: Telephone: ( 3 <br /> Physical Address: <br /> Mailing Address: <br /> �i <br /> E. DESCRIPTION <br /> Type of Discharge: e l� <br /> Volume: <br /> i � <br /> Chemicals: <br /> R <br /> Circumstances: Y f <br /> F. ACTION TAKEN <br /> I :Y <br /> :1 <br /> SITE DISPOSITION <br /> EH 22 013 (Rev-4/91) <br /> I� <br />