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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 FILE CODY <br /> A. EMERGENCY LEVEL&II III PHS-EH LOG <br /> (Circle One) <br /> B. SOURCE F INFORMATION <br /> Name: Phone: (416) 3��1– 6 <br /> Company: 02 ZL41 . <br /> Address: rc, Oct 5 <br /> Designated Employee Name: Phone: [_) <br /> Reporting Agency Name- <br /> Address: <br /> C. LOCATION AND DATE OF qISCHARGE <br /> Location: X05 Co.s-rn —/ <br /> (Best Physical Description) ty or County) Circle One <br /> Date of Discharge: <br /> Date Notified: `i Time: g •D 0 � <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: <br /> Physical Address: 4�— <br /> Mailing Address: o cy; <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: M <br /> Circumstances: <br /> F. ACTION TAKENL6 az Lzmyagg.,p <br /> anz_ <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.4/91) <br />