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JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> i <br /> EMERGENCY LEVELf�II III <br /> � PHS-EH LOG # C%''�l <br /> A. EMERG (C rcle One) I <br /> B. SOURCE OF INFORMA'T'ION � �� phone• �< < F��� -3 7'? <br /> Name:_ <br /> Company: <br /> Address: / 7 iv �,��w / Phone: <br /> Designated Employee Name: _ 77-17 y t �� �.�, /i� S -�<C-e-s <br /> Reporting Agency Name: <br /> Address: s' <br /> C, LOCATION AND DATE OF DISCHARGE <br /> Location: ��'" '`� �'�'�'` ` ✓ � (City or County) a One <br /> •(Best Physical Description) <br /> Date of Discharge: <br /> Date Notified: <br /> � -/i- �.z-- � Time: <br /> D. RESPONSIBLE PERSON/BUSINESS/� <br /> Name of Business: _ Telephone: `���s -s� 7S <br /> v" <br /> Contact Person:' --------------- <br /> Physical Address: <br /> Mailing Address: S <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: . ;:-Z ! L j <br /> Circumstances• :5-: ,- <br /> -. <br /> F. ACTION TAKEN <br /> SITE DIS?OSIT_ION - - <br /> � , -Y �,�� /'rte i» �n c• G <br /> ------------ <br /> EH 22 013 (Rev-4/91) <br />