Laserfiche WebLink
SAN .TOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DGSCrFARGE <br /> HEALTH & SA=E_ CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG m <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: U <br /> Company:_ . <br /> Address: •-• . <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: 3otk z.. <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Description) County) Circle One <br /> Dare of Discharge; <br /> Daze Notified: <br /> D. RESPONSIBLE PEERSO"USINESS <br /> Name of Business: <br /> ContacrPersia:_;, n.� � izzE2 ic_t Telephone: <br /> Physical Address: .i5r,- o 444, Q"\ <br /> Mailing Address: - — <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAMN lila <br /> Si'I'E DISPOSITION '. EC <br /> EH 22 013 (Rev.4191) <br />