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0 SAN JOAQUIN COUNTY <br /> NOTIFIC' LION OF HAZARDOUS WASTE DIStl!iARGE <br /> HEALTH & SAFETY CODE 25180.7 COPY <br /> A. EMERGENCY LEVEL:0 II III PHS-EH LOG # /D — /o2 Z <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: ' �'i l ) (' Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name:..? Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OFI�HARGE. S 7L: / 570 G <br /> Location:-, l D <br /> (Best Physical Descriptig n) ` or County) Circle One <br /> Date of Discharge: -- <br /> Date Notified: F- / - f C, Time: / : 30 m , <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: z _ C <br /> Chemicals: - <br /> Circumstances: <br /> �. A ION TAKEN <br /> SITE STATUS ` <br /> EH 22 013 (Rev.4/91) <br />