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SAN JOAQUIN COUNTY <br /> NOTI "kTION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH . SAFETY CODE 25180.7 [� <br /> A. EMERGENCY LEVEL: III III PHS-EH LOG #_ <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: <br /> Comp Phone: <br /> anY: <br /> S�b`�S�Q g�jp <br /> _--rr� ,n ,S-� �� to I , <br /> Address <br /> Designated Employee Name:_ Phone:Pho <br /> Reporting Agency Name: T • Ctzj - <br /> Address:_ A !„ o meq.. <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 33 3 c4- -,- I r <br /> (Best Physical Description) Ci <br /> Date of Discharge: or County) Circle One <br /> i v_ _g .�- <br /> Date Notified: — /2 -2-5k.5 Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: p-t-�- }�� ,��� o Telephone: Coo ) <br /> Physical Address: at�� �� <br /> Mailing Address: PA <br /> '` �A <br /> r�X� <br /> E. DESCRIPTION <br /> Type of Dischar e: U r� <br /> Volume: <br /> Chemicals: <br /> Circumstances <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> CH 22 013 (Rev.4/91) <br /> i <br />