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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF H ZARDOUS WASTE <br /> AS EDI CHARGE <br /> HEALTH & SAFE <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG # <br /> ( ircle One) <br /> B. SOURCE OF INFORMATION Phone: (f `� `� -7 <br /> Name: — <br /> Company: <br /> Address: �,�, Phone: !�� <br /> Designated Employee Name: <br /> Reporting Agency Name: ✓T/-jvCti z� 1 <br /> Address: �/// /-/' <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: '70e!2( � '� (Ci -or County) Circle One <br /> (Best Physical Description) <br /> Date of Discharge: <br /> Date Notified: Time; <br /> D. RESPONSIBLE PERSON/BUcINESS c, �� <br /> Name of Business: o� 7> x. ��`� - ' Q <br /> v�G-�-^�� Telephone: �, <br /> Cdntact Person: /� '�L�'=' L� � <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: '`-yam •�.r�iJ"t�''cY�/ <br /> Circumstances: <br /> �('KT•(/'� rrr'� <br /> F. .ON TAKEN <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.4/91) <br />