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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> OU HEALTH & SAFETY CODE 25180.7 <br /> D � <br /> FILE COPY _ <br /> A EMERGENCY LEVEL:� II III <br /> FH LOG ## <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: (_) <br /> Name: o <br /> Company: <br /> Address: Phone: (� <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DAT OF DIS HARE 11Location:(Best Physical D scriprion) Ai� <br /> o County) Circle One <br /> Date of Discharge: Time: Jo 0 <br /> Date Notified: �� n <br /> D. RESPONSIBLE PERSON/ USIrJESS <br /> Name of Business: fid` " a'`"`C Telephone: 514 6-7 <br /> Contact Person: <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> volume: <br /> Chemicals: <br /> Circumstan es: <br /> F. ACTION TAKEN �ZG <br /> Gc. o �cti. <br /> � OCU <br /> SITE DISPOSITION 6 <br /> e vie <br /> EH 22 013 (Rev-4/91) <br />