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SAN JOAQUIN COUNTY t w <br /> NOT' CATION OF HAZARDOUS WASTE SCHARGE <br /> HEALTH & SAFETY CODE 25180. / PC) � <br /> A. EMERGENCY LEVEL: ® II III PHS-EH LOG <br /> (Circle One) <br /> B . SOURCE OF INFORMATION <br /> Name : I' Phone: (2.db a 70 % <br /> Company: <br /> Address : <br /> Designated Employee Name: a Phone: (ad D llw/p 9/ - , 3 go, <br /> Reporting Agency Name: <br /> Address <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: _ 'f Ah (� C Fac / j /� G �( <br /> (Best Physical Description) Z ti or County Circle One <br /> Date of Discharge: <br /> Date Notified : S! — A �f — Y `i Time: ' D O P KM <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business : u. vr�� Q °�i. ' ch , <br /> Contact Person: Rgf Telephone: ( 21 <br /> Physical Address : <br /> Mailing Address : <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: —r <br /> Circumstances <br /> F. ACTION TAKEN <br /> MT <br /> SITE DISPOSITION <br /> � T <br /> EH 22 013 (Rev.4/91 ) <br /> I <br />