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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:�)H IIT PHS-EH LOG # q <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: <br /> Name: <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: �` x/68 3Y�"4 <br /> Reporting Agency Name: Z–i71 <br /> Address: 30 <br /> C. LOCATION AND DATE OF DISC GE <br /> Location: 33 <br /> (Best Ohysical De- ccriprio (City or Co Circle One <br /> Date of Discharge: G <br /> Date Notified: Time: &"a zz&; <br /> D. RESPONSIBLE PERSOP/BU I SSS <br /> Name of Business- <br /> Contact Person: Telephone: (713) 7 -7' <br /> Physical Address: S• �� G �, �1 <br /> Mailing Address: ri <br /> E. DESCRIPTION <br /> Type of Discharge: A <br /> Volume: Z/17 ew <br /> Chemicals: <br /> Circumstances: G Se � !" G �.� T7� »/ �✓ A "� <br /> F. ACTION TAKEN <br /> S7 $TATUS—j5/v- <br /> EH 22 013 (Rev.4/91) <br />