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SAN JOAQ UIN COUNTY COPY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> } <br /> A. EMERGENCY LEVELccle <br /> II III PHS-EH LOG # d One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: .C _) <br /> Company: <br /> Address: ` <br /> Designated Employee Name: Phone: _ <br /> Reporting Agency Name <br /> Address: <br /> C. LOCATION AND DATE F DISCHARGE <br /> Location: <br /> (B st Physical�es e-5or ption) County) Circle One <br /> Date of Discharge: — <br /> Date Notified: _ -3 -�r-+� _ Time: M -- <br /> -� <br /> D. RESPONSIBLE PER50,1�1/B ,�I <br /> ,UNESS <br /> Name of Business: OLIA <br /> Contact Person: Telephone: (7O <br /> Physical Address: Ua S <br /> Mailing Address: _.P-4)-/64_J k ' <br /> E. DESCRIPTION � "--c n��� <br /> { <br /> Type of Discharge: . w A - <br /> Volume: <br /> Chemicals: <br /> Circumstances <br /> F. ACTION TAKEN <br /> SITE STATUS_ 920 w.�.. — -, • mat t� - - <br /> i <br /> EH 22 013 (Rev.4/91) <br />