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1 ilii � i <br /> SAN JOAQUIN.COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 C(D <br /> } t r , <br /> i t ,', <br /> A. EMERGENCY LEVEL011 III PHS-EH LOG # /'3i <br /> ry (Circle One) <br /> i <br /> B. SOURCE OF INFORMATION <br /> Name: I Phone: (_) <br /> k Company: f--e4E' a60 -r-r,- <br /> Address: `I <br /> Designated Employee Name: Phone: (� <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DIS HARGE <br /> Location: <br /> (Best Physical Des nption) CWor County) Circle One <br /> Date of Discharge: r <br /> Date Notified: g I Time: Zb <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: r o L Telephone: (_) , s� <br /> Physical Address: <br /> Mailing Address: "I <br /> r <br /> E. DESCRIPTION <br /> Type of Disc argg: r <br /> volume: <br /> Chemicals: 7u-- x&E A <br /> Circumstances: IWs s <br /> C'o- lCfAC <br /> F. ACTION TAKEN A A-5 <br /> o f ' <br /> �h <br /> �p <br /> SITE STATUS -Z --z;, .P = u <br /> Ac?v 'zhY <br /> EH 22 013 (Rev.4/91) <br />