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vIrv,l <br /> .. SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE copy <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: �) <br /> Company: U S <br /> Address: <br /> Designated Employee Name: Phone: L� <br /> Reporting Agency Name: <br /> Address: ?5� 'E S�E VV5!7-- <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 2q"O \�Zd111 Cezz%T tE / <br /> (Best Physical Description) (City oroun Circle One <br /> Date of Discharge: : R,,!) QC, <br /> Date Notified: / irl ./ 4c, Time: ICS nn m <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: L� <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: -."20 r,—; cr L <br /> Volume: <br /> Chemicals: <br /> Circumstances <br /> F. ACTION TAKEN t �) nlo<a¢�rI <br /> SITE DISPOSITION <br /> .NcrP�-f- <br /> EH 22 013 (Rev.4/91) <br />