Laserfiche WebLink
SAN JOAQUIN COUNTY FILE COPY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVE I I III PHS-EH LOG# C '9 S p` <br /> ircle one) <br /> B. SOURCE OF NFORMATION <br /> Name: �// ��/�� Phone: ( ) <br /> Company: ;. <br /> Address: i'Q S <br /> Designated Employee Name: P one: <br /> Reporting Agency NameL� <br /> Address: '.e47 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> J D1 L(J 5'TI�ZA xC11 I -/4�l <br /> Location: <br /> (Best Physical escription) C County} Circle one <br /> Date of Discharge: / <br /> Date Notified: Time: G,o <br /> D. RESPONSIBLE PERSONIBUSINESSS <br /> Name of Business: <br /> Contact Person: Phone: <br /> Physical Address: <br /> Mailing Address: 70 -? 7 10 <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE DISPOSITION ' <br /> EH 22 013 (Rev. 08120198) <br />