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0 <br /> �-r-� SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL II III <br /> PHS-EH LOG# <br /> Zr-ircle one) <br /> B. SOURCE OF INFORMATION <br /> yv Phone: 06 <br /> Name: <br /> Company: <br /> Address: Phone: /6 <br /> Designated Emp oyee Name: > <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE � <br /> rAw� ,S� l Sf"D � <br /> Location: ,� S Lt% (City or County) Circle one <br /> (Best Physical Description) <br /> Date of Discharge: �64Time: A :0 <br /> YYU <br /> Date Notified: 7-5 - <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: Phone: -20 C13-7— <br /> Contact <br /> 3-7Contact Person• t Q <br /> Phvsical Address: <br /> Mailing Address: -5�t.�'►'� <br /> E. DESCRIPTION <br /> Type of Discharge: Wf'T <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN Q <br /> r <br /> SITE DISPOSITION <br /> Q _ <br /> EH 22 013 (Rev. 08/20/98) <br />