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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE � ` r,7-'7-", Y7 <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: . I I III PHS-EH LOG # 3 _� <br /> ( cle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company: 1J <br /> Address: <br /> Designated Employee Name: -f7' ci 0 S Phone: <br /> Reporting Agency Name: `! <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: � 67 ,M IL4,In / J <br /> (Best Physical Description) City r County) Circle One <br /> Date of Discharge: <br /> Date Notified: / f=I Time: <br /> D. RESPONSIBLE PERSON/BUSINESS ; <br /> Name of Business: - SI" 'f' <br /> Contact Person: a-P•r Telephone: .—, <br /> Physical Address: <br /> Mailing Address: �,5'-3 IVA H Clh <br /> T <br /> E. DESCRIPTION <br /> Type of Discharge: 14 4 <br /> Volume: <br /> Chemicals: <br /> Circumstances: ` c % l <br /> 641 /A <br /> � ` �-c-• <br /> F. ACTION TAKEN <br /> SITE,5TATUS <br /> al:f <br /> EH 22 013 (Rev-4/91) <br />