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t r <br /> SAN°JOAQUIN COUNTY �. <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVELI II III PHS-EH LOG # qq <br /> (Circle One) <br /> t r <br /> B. SOURCE OF INFOfIMATION - <br /> Name: X Phone: (20.t S6—do-?,6 S/ <br /> Company: <br /> Address: ` 3 <br /> Designated Employee Name: Phone: QeD Sys <br /> Reporting Agency Name:S �` <br /> Address• ', 4 S <br /> C. LOCATION AND DATE OF DISC GE <br /> Location: <br /> 3(Best Physical Description) _ (Ci r County) Circle One <br /> Date of Discharge: <br /> Date Notified: 1 Time: l/J:OD �'I• _- _"__ <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> :. Contact Person: : elephone: Wig) 24E- <br /> Physical Address: �--- <br /> Mailing Address: l <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: CSS d�' <br /> Circumstances: e <br /> F. ACT ON.TAKEN S7� 3 <br /> rz <br /> SITE STATUS (JS G e <br /> a Si <br /> EH 22 013 (Rev.4/9 i) <br />