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- ' . SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL•111 IIIPHS-EH LOG # <br /> 6:ircle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (:�20 <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: is i �+ ; <br /> 7 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> /;j, /,!�> /__:�7 - <br /> Location: _ ', Z e ', GJ ---- <br /> (Best Physical Description) qty car County) Circle One <br /> Date of Discharge: <br /> Date Notified: L, Xi Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: zL�, ---/ <br /> Contact Person: Telephone: (LY3 <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: . <br /> Volume: <br /> Chemicals- <br /> Circumstal e7lez <br /> F. ACTION TAKEN A, <br /> SITE DISPOSITIONej- -,9 e- <br /> EH 22 013 (Rev.4/91) <br />