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4b % <br /> SAN JOAQUIN COUNTY C��"'t'�� COPT <br /> NOTIFICATION OF HAZARDOUS WASTE DIS �'�` <br /> gEALTH & SAFETY CODE 25180.7 _ <br /> A. EMERGENCY LEVEL: I II III <br /> PHS-EH LOG 0 3 `d d o <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Name: <br /> �� _rJ Phone: ( ) <br /> Company: Sautti t-733 <br /> Address: Z4 2 <br /> Phone: <br /> Designated Employee: me: �C <br /> Reporting Agency Name: 5' Samoa•• �'�""`�` �'� <br /> Address: 30 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: o SCi or County) Circle one <br /> (Best Physical Desc tion) <br /> Date of Discharge: V Time: <br /> Date Notified: 3 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> ,1 , 1 <br /> Q=.II lQag W n� � <br /> Name of Business: Phone. gig XRT 7� 'moo -- <br /> Contact Person: c- t{; is e A 3 0 <br /> Physical Address: c'� <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: V t <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN u t s <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.08120/98) <br />