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SAN JOAQUIN COUNTY ) <br /> NOTIFICAi..,)N OF HAZARDOUS WASTE DISCa-,-.tRGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # f ( 3 <br /> Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: G��c�, ��� � ���,/n _ Phone: /O 3-72, <br /> Company: <br /> S�—. .-- <br /> Address' <br /> Phone: vp <br /> Designated Employee Name: Gc«o/ c'7— �..). <br /> Reporting Agency Name: A V/� <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: l,;l s, <br /> (Best Physical Description) City r County) Circle One <br /> Date of Discharge: ��leer a4,, . <br /> Date Notified: -e/;Y/g/ Time: %M <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: G,-e( ou., - <br /> Contact Person: Telephone: y <br /> Physical Address: <br /> Mailing Address: su ° <br /> E. DESCRIPTION q <br /> Type of Discharge: <br /> Volume: /r, -) <br /> Chemicals: X,ie <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> Al <br /> v <br /> v <br /> EH 22 013 (Rev.4/91) <br />