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SAN JOAQUIN COUNTY Uk� <br /> NOTIFICATION OF HAZARDOUS WASTE DISCH.AR f IL E HEALTH <br /> HELTH & SAFETY CODE 25180.7 <br /> I <br /> A. ENIERGENCY LEVEL Imo/ II 111 PHS-EH LOG? no <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Name: <br /> Phone.R4) <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: ,�/I� <br /> Reporting Agency Name: illi! �" <br /> r <br /> Address: <br /> C. LOCATION AMD DATE OF DISCHARGE <br /> Location: / G i r County} Circle ane <br /> (Best Physicai Desc}ption) <br /> Date of Discharge: 2 <br /> Time: <br /> Date Notified: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> dame of Business: J �� <br /> Phone:a J� <br /> Contact Person: <br /> Physical Address: <br /> LvIailinig Address: D <br /> E. DESCRIPTION y� <br /> Type of Dischar;e: <br /> Volume: U <br /> Chemicals: + __ <br /> C ircurnstances: <br /> L <br /> �. ACTION T.k EN <br /> lot <br /> v� <br /> SITE DISPOSITION <br /> EH 22 0 l3 (Rei•. 08!'_a193) <br />