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SAN JOAQUIN COUNTY i <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> I�. IRp <br /> A. EMERGENCY LEVEL:a)II III F (DFIYH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION - <br /> Name: c( 3 S �, t Phone: <br /> 7 <br /> Company: j �1 <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: 11 • Vit. <br /> Address• 4 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> r �7 <br /> Location: / <br /> (Best Physical Description} ,ir ity or County) Circle One <br /> Date of Discharge: • .U-1)--- <br /> Date <br /> U)-`.- <br /> Date Notified: I l Time: ` Dv <br /> D. RESPONSIBLE PERSON/BUSINESS i <br /> Name of Business: <br /> � Contact Person: Telephone: -75 '/G 7k <br /> Physical Address: Lan <br /> Mailing Address: !# 3 <br /> E. DESCRIPTION °. # <br /> Type of Discharge: <br /> Volume: <br /> Chenucals: <br /> Circumstances• G ? <br /> F. ACTION TAKEN �1� ` <br /> i <br /> SITE DISPOSITdf <br /> IONp <br /> t GYir G-Cis c _c f <br /> 0, tt�- <br /> k I <br /> :I M <br /> II <br /> EH 22 013 (Rev.4/91) S, <br /> I� <br /> 3 <br /> -1 <br />