Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUSWASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:(9I III PHS-EH LOG # t <br /> (Circle One) <br /> ' I <br /> B. SOURCE OF INFORMATION <br /> i <br /> Name- Phone: (,Cry) <br /> Company: <br /> Address: 0.. <br /> Designated Employee Name: r Phone: (2i3j, <br /> Reporting Agency Name-L--,7'.o,, QT t� <br /> Address: d� C <br /> C. LOCATION AND DATE OF DISC GE <br /> Location: / 4c.1 61 <br /> (Best Physical D scn' tion) (Ci or C unty) Circle One <br /> Date of Discharge: <br /> Date Notified: Time: 7� 1 <br /> 3 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: V a <br /> Contact Person: Telephone: <br /> Physical Address: <br /> Mailing Address: , A.;Z �153—' r n ge' <br /> E. DESCRIPTION <br /> Type of Discharge: ©P <br /> Volume: <br /> Chemicals: s?� <br /> Circumstances: — f <br /> f <br /> F. ACTION TAKEN <br /> SITE STATUS <br /> EH 22 013 (Rev.4/91) <br />