Laserfiche WebLink
SAN JOAQUIN COUNTY t <br /> NOTIFI�ION OF HAZARDOUS WASTE DI86-?IARGE <br /> HEALTH & SAFETY CODE 251iM71 <br /> C(apy, k ' <br />{i A. EMERGENCY LEVEL <br /> • I If ill PHS-EH 1OG # <br /> rcle One) <br /> B. SOURCE OF INFORMATIQN hl ij. k <br /> Name: elPhone: <br /> Company: <br /> Address: SZ <br /> Designated Employee Name: phone: <br /> I Reporting Agency Name: :If' <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE k <br /> Location: P'� 19. <br /> i <br /> (Best Physical Description) - ->jli Ci r County) Circle One <br /> Date of Discharge: !Ili . <br /> bate Notified: D a s Time: <br /> D. RESPONSIBLE PERSON/BU INESS , . <br /> ii <br /> Name of Business: . <br /> Contact Person: K4.64-r4' Tdle hone: <br /> Physical Address: `06 � <br /> Mailing Address: <br /> E. DESCRIPTION ! <br /> i <br /> Type of Discharge: bI �I <br /> Volume: _ --- - t A nn�R!�F' Z�?� li �� ------ <br /> Chemicals: ( he <br /> Circumstances: i <br /> II n <br /> Q <br /> il. I <br /> F. ACTION TAKEN_ I.t9yl�, , <br /> .II it • •..,..,.,,. -- <br /> 'Ib 4 <br /> A I {{ <br /> f <br /> SITE DISPOSITION r <br /> OC S (•l U ea4 S i ke <br /> 1 k II ;� <br /> II ,�li <br /> II �p <br /> EH 22 013 (Rev.4/91) <br /> is <br />