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'COUNTY <br />SAN JOAQUIN <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFE'T'Y CODE 25180.7 n py <br />(C(a <br />A. EMERGENCY LEVEL R III <br />PHS -EH LOG # <br />(Circle One) <br />B. SOURCE OF INFORMATION Phone: <br />Name: <br />Company: %10 P <br />Address: %`-�e: (_.� <br />Designated Employee Name: <br />Reporting Agency Name: <br />Address: <br />C. LOCATION AND DATE OF D <br />Location: ��S <br />(Best Physical Desca <br />Date of Discha!�Nft <br />Date Notified: <br />0 <br />E <br />RESPONSIBLE PE <br />Name of Business <br />Contact Person: _ <br />Physical Address: <br />Mailing Address: <br />n <br />or County) Circle One <br />Time () v <br />DESCRIPTION <br />Type of Discharge.- <br />� <br />volume: <br />Chemicals: �,� D CE <br />Circumstances:e <br />F. ACTION TAKEN <br />SITE STATUS <br />EH 22 013 (Rev.4191) <br />