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SAN JOAQULr COUNTY FILE COPY <br /> NOTEFICATION OF HAZARDOUS WASTE DISCHAR <br /> HEALTH & SAFETY CODE 2180.7 <br /> A. EMERGENCY LEL: I II III PHS-EH LOG T <br /> rcle one) <br /> B. SOURCE OF INFORMATION <br /> Name: o� A)ee Phone:�(��/ <br /> Company: 4/,17 r411-, <br /> Address: 701 ,�f -. <br /> Designated Employee dame: ' 9'H Phone: <br /> Reporting Agency Name: L% J <br /> Address: D�/ - <br /> C. LOCATION <br /> /AND DATE OF DISCH.-kRGE <br /> Location: <br /> (Best Physical Description) Cit} or Count) Circle one <br /> Date of Discharge: � L�� <br /> Date Notified: v �� Time: <br /> D. RESPONSIBLE PERSONBUSNESS <br /> Name of Business: t 11, <br /> Contact Person: Phone: <br /> Physical .address: � <br /> Mailing address: 2ttZ r17 2VT49, <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN ZO'Ye <br /> SITE DISPOSTITON /j t1fP 06g ' <br /> EH 22 013 (Rev. 08/20/98) <br />