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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 u <br /> A. EMERGENCY LEVEL:(a--,�I III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: L� <br /> Company: . � <br /> Address: <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE r <br /> Location: 7� <br /> (Best Physical D cription� <22�r County) Circle One <br /> Date of Discharge: U <br /> Date Notified: /v io Time: , /8=00 4� <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: �5fF,6-- 32�7 <br /> Physical Address: <br /> Mailing Address:E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TARN <br /> SITE STATUS <br /> r-2-` <br /> EH 22 013 (Rev.4/91) <br />