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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE ' <br /> HEALTH & SAFETY CODE 25180.7 <br /> G <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <br /> ( ircle One) <br /> B. SOURCE OF INFORMATION ZZ6`� <br /> (2a)Phone: ( <br /> Name: <br /> Company: _ �- <br /> Address: -SfiO`'� ''' (� <br /> Designated Employee ame: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATIO AND DATE OF ISCHARGE / SG <br /> Location: 3 '` <br /> (Best Physical es ription) (City or County) Circle One <br /> Date of Discharge: 7 /57 gs <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERS/BUSIN S <br /> Name of Business: <br /> Contact Person: Telephone: <br /> co <br /> Physical Address. 900�.�- <br /> Mailing Address:7M <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: 2- <br /> Circumstances:s. <br /> F. ACTION TAKEN_3�:Lt�� <br /> SITE STATUS <br /> IL <br /> �u <br /> EH 922 013 ( ev.4/91) <br />