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SAN JOAQUIN COUNTY <br /> NOTIFT TION OF HAZARDOUS WASTE 61-:5CHARGE <br /> HEALTH & SAFETY CODE 25180.7_ <br /> r - <br /> A. <br /> EMERGENCY LEVEL: I II III PHS-EH LOG # /\c . <br /> ( ircle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: Q336 <br /> ��- <br /> Name: �r'� . <br /> Company: <br /> Address- o <br /> Designated Employee Name: 3 l 3145.111W,14 Phone: (22jj V1040.5367 <br /> Reporting Agcy Name:,5;� oa I <br /> Address: 3Y wog 56L� tff Qz;pO t <br /> C. LOCATION AND DATE OF DISC GE 11 <br /> Location: /-7/ 7 -f �'P,yI� �T <br /> (Best Physical Des 'ption) Ci or County) Circle One <br /> Date of Discharge: <br /> Date Notified: Jgz Time: <br /> D. RESPONSIBLE PERSON NESS����� �r <br /> Name of Business: •� <br /> Contact Person:'_ Gr Telephone: (LY1) <br /> Physical Address: � aD77 <br /> Mailing Address: /,3oeGv <br /> E. DESCRIPTION /� k- <br /> Volume: <br /> Type of Discharge: LIQ <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN UST TGYYI o� 5b d obs <br /> SITE DISP SITION <br /> G <br /> u <br /> EH 22 013 (Rev.4/91) <br />