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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE;DIS „ <br /> HEALTH & SAFETY CODE 25180.7 LP y <br /> . (�(� //-- <br /> A. EMERGENCY LEVEL. I II III „� PHS-EH LOG ! ! 0"56, 1 <br /> (Circle one) I <br /> B. SOURCE OF INFORMATION { <br /> Name: Phone: (,<70) 64_3 <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE , t <br /> Location: / <br /> (Best Phvsi i Description) or.County) Circle one <br /> Date of Discharge <br /> Date Notified: y Time: <br /> D. RESPONSIBLE PERSONIBUSINESS <br /> Name of Business: <br /> Contact Person: Phon :1O°t -<O <br /> Phvsical Address: A <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: r <br /> Volume: 64wk- <br /> Chemicals: <br /> CirCinlZumst ric / U -� / S <br /> F. ACTION TAKEN Z iu <br /> SITE DISPOSITION •W "� <br /> w <br /> d--P <br /> r <br /> EH 22 o 13 (Rev. 08/20/98) <br />