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• SAN JOAQUIN COUNTY • PY <br /> NOTIFICATION OF HAZARDOUS WASTEDI CHARGEC O <br /> HEALTH & SAFETY CODE 25 <br /> a�� 6 - <br /> A. EMERGENCY LE <br /> VEL. I II III PHS-EH LOG # J <br /> ( ircle One) <br /> B. SOURCE O INFORMATION c g0 Z • 233 <br /> itFSfv> �cc 77 Phone: <br /> Name: f v <br /> Company: d P <br /> Address: Phone: (� <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF ppI CHARGE <br /> Lo-atio ^_� hn�,f. iii G�TsI �plf.E6E/Rl/ / <br /> (Best Ph ical Description) <br /> l�/Fr,C City or County) Circle One <br /> Date of Discharge: O/VkA10u/n/ <br /> Date Notified: 4 1005 /9Q2' Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: I� _ p3 <br /> Contact Person: Telephone: <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: ' <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> f <br /> F. ACTITAKEN <br /> SITE STATUS <br /> L+-o <br /> EH 22 013 (Rev.4/91) <br />