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�j <br /> SAN JOAQUIN COUNTY f <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY Lr:VEL:D It tit PNS-EH LOG # J I <br /> (Circle One) <br /> ^u. SOURCE OF INFORMATIO <br /> Name• * Phone: `2- „a <br /> 0 6 -/ <br /> Company:.l <br /> Address:— /as <br /> Designated Employee Name:, Phone: (� <br /> Reporting Agency Naine: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Descriprion) ��5yor County) Circle One <br /> Date of Discharge: <br /> Date Notified: Time: - <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: _ Telephone: <br /> Physical Address: A 1- - C�• 3�tXc <br /> h41iling Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume- <br /> Chemicals: <br /> Circumstances: .7- aA.4-^-c <br /> F. ACTION TAKEN <br /> �uf� <br /> Sm. DISPOSITION .S•77 <br /> U <br /> !t __�%►lei <br /> EH 22 013 (Reti•.4/91) <br /> t <br />