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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE nO [PAY <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:0II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: <br /> Name: (. ) <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: (� <br /> Reporting Agency N e: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE Go�� <br /> Location: <br /> (Best Physical Descn tion) (Cir 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: 6 <br /> Mailing Address: " <br /> E. DESCRIPTION <br /> Type of Discharge: `�� 7 �0 <br /> Volume: ���� ow <br /> Chemicals: -r7LcE eel- <br /> Circumstances: <br /> rCircumstances <br /> F. ACTION TAKEN Ale- <br /> SITE STATUS 72::, <br /> dr= Co �4.4rr -4- <br /> EH 22 013 (Rev.4/91) <br />