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47 SAN JOAQUIN COUNTY <br /> kf 1FI&'U4ON OF HAZARDOUS WASTE DISARGE <br /> 180.7 <br /> \ HEALTH & SAFETY CODE 25180.7 <br /> A. <br /> kERGENCY LEVEL: II III EH LOG # 3~ 0 3 S <br /> ( ircle One) <br /> B. SOURCE O INFO ON -02,q <br /> - <br /> Name: Phone: ( , <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE Of DIS HAR i <br /> Location: d U41 <br /> (Best Physical Descriptio r County) Circle One <br /> Date of Discharge: �� <br /> Date Notified: T e� =On "^' <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Teleph e: { <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: GtS� <br /> Volume: O.AA%A. <br /> Chemicals: A <br /> Circumstanc s: /98 <br /> F. ACTION T DV - a5l- �a P <br /> SITE DISPOSITION a <br /> Q <br /> EH 22 013 (Rev.4/91) <br />