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f �,✓ SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> \�✓ / V <br /> A. EMERGENCY LEVEL:CI, II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: : � <br /> Company: ��- �.r•! �'� <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: i/�l �,,: <,,,�-�,' d ,� �✓ ter-;_r_� „r� '= <br /> C. LOCATIONAND DATE OF DISCHARGE <br /> Location: "�49 / 4:;--7 7 2-- / <br /> (Best Physical Description) 0City or County) Circle One <br /> Date of Discharge: '!��I. �T/��z��.l '� <br /> Date Notified: Time: Y <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person:- Telephone: <br /> E Physical Address: - <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: �^14 � - <br /> Volume: <br /> Chemicals: R65i�,7v4,4�' <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> � �✓.mac �f-U'7 ,=-;r.�.-�„�- �r �'=-�[%,.�l�-i-'�/ f'f`�'���•. / <br /> EH 22 013 (Rev.4/91) <br />