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SAN JOAQUIN COUNTY ili! r <br /> NOTIF[CATION�OF HAZARDOUS WASTE DISCHARGE € / <br /> II .,.. <br /> HEALTH & SAFETY CODE 25180.7 (0)L. <br /> ,i. <br /> A. EMERGENCY LEVE II III iF PHS-EH LOG # 11i? C �� <br /> xrcle One) IF <br /> B. SOURCE OF INFORMATION �i, <br /> Name: Phone: �) <br /> Company: i!. <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agenc Name: ff5 EH 11; <br /> Address: 5 Ua <br /> C. LOCATION D DATE OF IS IH_ARGE <br /> Location: 2 / <br /> (Best Physical Description) (City r County) Circle One <br /> Date of Discharge: - <br /> Date Notified: 1 I-1Z--!y Time: <br /> D. RESPONSIBLE PERS N/BUSINESS <br /> Name of Business: <br /> le <br /> ' Contact Person: � � TePhon,e: (W9), -6 3 <br /> Physical Address: LIZ3 At. II <br /> Mailing Address: Zq 31 <br /> E. DESCRIPTION <br /> Type of Discharge: fa <br /> Volume: i II <br /> Chemicals: iW4 // 50l vlel" l; <br /> Circumstances: &r.5Q na I &1O 4 arm ri <br /> , <br /> F. ACTION TAKEN 0 <br /> S TE DISPOSITION S f <br /> l G <br /> v 51 <br /> !!; <br /> c <br /> s <br /> EH 22 013 (Rev.4/91) , <br />