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F <br /> SAN JOAQUIN COUNTY !;, Copy <br /> NOTIFICATION OF HAZARDOUS WASTE DISC#ARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: IIIII PHS-EH LOG <br /> �( irele one) <br /> B- SOURCE OF INFORMATION <br /> Name: < 1,112 ' i ! Phone: <br /> Company: .,' l L %..i" "J I'i �` 2- (-i•/ "i r'J `t�j '! <br /> Address: 1 l <br /> Designated Employee Name: '•., Phone: <br /> Reporting Agency Name: F,~ <br /> Address: 3p 4 We- <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: v t}'_) I OD <br /> (Best Physical Descn tion) (C County) Circle one <br /> Date of Discharge-, `L.�� - <br /> i <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSOWBUSINESS <br /> Name of Business: (-I( ri <br /> Contact Person: I V+ f ti'', Phone: <br /> Phvsical Address:"l00 V\Jk.r - <br /> Mailing -address. ; o V- > <br /> E. DESCRIPTION 44 <br /> Type of Discharge: (Irl 0 UUf I 'U hf�l1� <br /> Volume: - <br /> Chemicals: ( G <br /> Circumstances: <br /> F. ANION TAKEN %' 1 �" 1 �`�.' VrA, <br /> P. <br /> SITE DISPOSITION m( -1 ) `i(,{ �; 11 CAK- <br /> U �. <br /> EH 22 013 (Rev. 08/20/98) <br /> I '. <br /> . I <br />