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risk <br /> SAN JOAQUIN COUNTY � <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHAR <br /> HEALTH & SAFETY CODE 25180.7 j <br /> + n' <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # L5 U4 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: '-�'�`Lv- ,�!` r q Phone: a Q Z? 3 <br /> Company: <br /> Address: <br /> Designated Employee Name:-LZc Phone-.,6Z <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AN DATE OF DISC E <br /> Location: �2 6 X), <br /> 7� Ci or County) Circle One <br /> (Best Physical Descri tion) (City tY) <br /> Date of Discharge: / 7`' ' j��' F3 <br /> Date Notified• — Time: <br /> D. RESPONSIBLE PERSON/BUSI SS <br /> Name of Business: CC., �' , <br /> Contact o Telephone: y � <br /> Physical Address: <br /> Mailing Address: Q 0 <br /> T <br /> E. DESCRIPTION �Tr�h" <br /> Type of Discharge: ` <br /> Volume: " p <br /> Chemicals: va <br /> Circumstances: <br /> F. ACTIO TAKEN <br /> S1111-� ell <br /> / D <br /> A <br /> SITEP ITION <br /> s� <br /> EH 22 013 (Rev.4/91) <br />