Laserfiche WebLink
SAN jOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALT'ri & SAFETY CODE 25180.71 I <br /> 5 <br /> ,r <br /> i <br /> A. EMERGENCY LEVEL: I [I III PHS-EH LOG 4— <br /> ( ' cle One) <br /> 't <br /> B. SOURCE OF INFOFLMATION I phone: LJ 'Z�00/ <br /> Name: � ' <br /> / <br /> Company: <br /> 62YO (1AAddress: <br /> F-0 - Phone: <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: <br /> ON AND DATE OF DISC GE <br /> C. LOCATION /� �. � <br /> Location: �} <br /> (Best Physical Description (City r County) Circle One <br /> Date of Discharge: ;o <br /> Date Notified- Time: <br /> D. RESPONSIBLE PERSON/ SINES-0 <br /> Name of Business: <br /> Contact Person: A 11 Telephone: 1 f <br /> Physical Address: <br /> Mailing Address: <br /> { <br /> E. DESCRIPTION <br /> IE Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Cir t5 ces: <br /> F. ACTION TAKEN <br /> I <br /> 9 <br /> SITE DISPOSITION 3 <br /> } <br /> EH 22 013 (Rev-4/91) <br />