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SAN JOAQUIN COUNTY <br /> NOTIPYRTION OF HAZARDOUS WASTE IWCHARGE .r <br /> I-IEAUI'H & SAFETY CODE 25180.7 <br /> 6 <br /> A. EMERGENCY LEVEL:©II III a. PHS-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFORMATION . <br /> Name: Phone: C__) <br /> Company: <br /> Address: .30oS /Zo <br /> Designated Employee Name: 01Phone: (_) <br />` Reporting Agency Name: <br /> Address: <br /> i <br /> C. LOCATION AND DATEAF DIS CHAR E <br /> Location: <br /> (Best Physical De ripCion) its or County) Circle One <br /> Date of Discharge: 0-�1 <br /> Date Notified: Time: 0 per. <br /> D. RESPONSIBLE PERSON/BUSINESS ` <br /> Name of Business: <br /> Contact Person: Telephone: Zo 6-SX x-i <br /> Physical Address: a 0 <br /> Mailing Address: <br /> y <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: , <br /> Chemicals: _ <br /> Circumstances: <br /> - i <br /> F. ACTION TAKEN A6 ac-g Y--L � <br /> SITE DISPOSITION a..5. 7- .W U <br /> Deo <br /> i <br /> e <br /> EH 22 013 (Rev.4/91) <br /> v <br /> .I <br />