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SAN JOAQUIN COUNTY <br /> NOTIFILr -;JN OF HAZARDOUS WASTE DISC ARGE <br /> HEALTH & SAFETY CODE 251$0.7 �; r <br /> A. EMERGENCY LEVELI III PHS-EH LOG <br /> b 1 � �O• j <br /> (Gucle One) <br /> B. SOURCE OF INFO O <br /> Phone: &z2) 7�+ OGIoTj <br /> Name: <br /> Company: , <br /> Address: <br /> Designated Employee.Name: G ` Phone: r4r) <br /> Reporting Agency-Name: <br /> 17� <br /> Address: <br /> C. LOCATION' DA7, OF DIS=25 <br /> } i <br /> Location:, <br /> (Best Physical Descri tion) mor County) Circle One <br /> Date of Discharge: <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: f <br /> Contact Person: r I Telephone: <br /> Physical Address: .:Qr <br /> 1Aj41z,25 <br /> Mailing Address: a � <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: CSS �1 w ?' <br /> Circumstances:, ��,rFri of Sd« GSvG'ri ��2o� �T'�dr-�t1 F •�-l� <br /> F. ACTION TAYE-4 f Q '! <br /> is <br /> SITE DISPOSITION <br /> f <br /> EH 22 013 (Rev.4/91) <br /> 3 <br />