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SAN JOAQ UIN COUNTY 0 <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: III III �-/ <br /> PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATIOI <br /> Name: L e,f -6' cc, <br /> J �' r S' Phone. <br /> Company: <br /> Address: <br /> Designated Employee Name: 7`—` ` ca_, Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: , • - <br /> (Best Physical Description) (City o ounty Circle One <br /> Date of Discharge: <br /> Date Nodfied: — Time: <br /> D. RESPONSIBLE PERSON/BUSINESS _ <br /> Name of Business: <br /> Contact Person: Telephone: c? Arta—5?j <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: T) CLI <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN <br /> J 1+- <br /> G ad 77 . <br /> r` <br /> SITE DISPOSITION S <br /> EH 22 013 (Rev.4/91) <br />