Laserfiche WebLink
SAN JOAQUIN COUNTY Y <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE "-'/ ry <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG # / O <br /> ( rcle One) <br /> B. SOURCE OF INFORMATION <br /> Name: a S Phone:, '3 y� <br /> Company: - ;2/Y S <br /> Address: <br /> Designated Employee Name: i S Phone: ,(�� °1/,20�-,-3 h � <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE /�J) <br /> Location: '7'f - � <br /> (Best Physical Description) J City r County) Circle One <br /> Date of Discharge: <br /> Date Notified: 3 —U — Time: <br /> D. RESPONSIBLE PERSO BUSINES <br /> Name of Business: <br /> Contact Person: J_ Telephone: 06�) 9 Y3 — 67S 7� <br /> Physical Address: _ <br /> Mailing Address: - D <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals /fix ;+ n 7 o�Yr o J /J Z`/.ia iz >_ <br /> Circu tances: C o <br /> / / <br /> F. A ON TAKEN <br /> / Y7 <br /> S E TATUS <br /> C � <br /> /iL'l �G�GIhfYG(�L� -.��L�'tCl � ! �c.v✓tGQ GJ'�rkCVL" �ZUGZ1 e�Cd�� <br /> EH 22 013 (Rev-4/91) <br />