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i SAN JOAQUIN COU-N= • <br /> NOTIFICATION OF r;gZARDOUS WASTE DISCHARGE <br /> DT:-i & SAFETY CODE 25180.7 <br /> HEAL <br /> LJ <br /> PHS-EH LOG <br /> A. EMERGENCY LEVE I III <br /> (Circle One) <br /> B. SOURCE F INFORMA ON �� Phone: �g" <br /> r <br /> Name: <br /> Company: Qlc� L S3G / <br /> Address: EF Deed Phone: <br /> Designated Employee Name: <br /> Reoorang Agency Name: <br /> Address: <br /> C. LOCATION AND PATE OF DISCHARGE <br /> Location: sC / n ) Circle OiCtyu <br /> BeshicaDeciption)t Physical <br /> Date of Discharge: UN�it1 DtJN <br /> 3•Z -O(v / Time: <br /> Date Notified: <br /> D. RESPONSIBLE PERSON/BUSINESS e <br /> Name of Business: 6« Telephone: (____3 <br /> Contac: Person: o <br /> Physical Address: 2� S 5205 <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Voiu_Tne: <br /> Chemicals: <br /> Circumstances: �� <br /> F. ACTION TAKEN <br /> r <br /> S.ice' STATUS <br /> EH 22 013 (Rev.4/91) <br />