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IV SAN JOAQUIN COUNTY <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVEL JI II IIILIP <br />PHS-EH LOG # <br />(Circle One) <br />U <br />B. SOURCE OF INFORMATION _ <br />Name: Phone: <br />Company: <br />Address: <br />Designated Employee Name:'�7 t_c,� K� Phone: <br />Reporting Agency Name: <br />Address: <br />ARGE <br />C. LOCATION AND DATE OF D <br />Location: i a 3 (7� (O�- <br />(Best Physical De,�cription) <br />Date of Discharge: <br />Date Notified: 1 i - I — 9 ,) <br />D. RESPONSIBLE PERSON/ USINESS <br />Name of Business: c� <br />E <br />F <br />Contact Person: <br />Physical Address: <br />Mailing Address:' <br />/ k,.,.-, �� <br />(� or County) Circle One <br />Time: 5-,. 0 O <br />Telephone: <br />DESCRIPTION / <br />Type of Discharge: <br />Volume: U.-�i -roc k. <br />EH 22 013 (Rev.4/91) <br />