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! ; SAN JOAQUIN COUNTY ��� <br /> CATION OF .HAZARDOUS WASTE DISCHARGE <br /> NOTIFICATION <br /> HEALTH & SAFETY CODE 25180.7 u <br /> A. EMERGENCY LEVEL:O II III PHS-EH LOG #_ -- <br /> (Circle.One) <br /> 13. SOURCE OF INFORMATION <br /> Name:_ W - _.. Phone: <br /> Company: a r <br /> Address: r r�S N -�-c� - - _J - <br /> Designated Employee Name:-- Phone: <br /> Reporting Agency Name: <br /> Address: ' <br /> I <br /> C. LOCATION AND DATE F D S HARGE. <br /> Location: I �� C / <br /> (Best Physical Description) (City or.County) Circle One <br /> Date of Discharge: <br /> Date Notified: I I _ Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: a Telephone: (?b! }IT33—' <br /> Physical-Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> S , <br /> F. ACTION TAKEN 7 <br /> SITE STATUS (AS T <br /> - I <br /> V`.11 ,22 013 (Rev.4/91) s <br /> i <br />