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SAN JOAQUIN COUNTY <br /> NOTAMATION OF HAZARDOUS WASTE IT.TCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> C <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG <br /> ( cle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Dr i V�ysZ V1 u Ax-yn twerUa--Q Phone: <br /> Company: <br /> Address: r ( <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATIOND DATE OF DISCHARGE <br /> Location: �Z O / ed � <br /> (Best Physical Des c ' tion) Ci or County) Circle One <br /> Date of Discharge: <br /> Date Notified: =7 Time:_ 5,OD p yam_ <br /> D. RESPONSIBLE PERS/BU,SINESS <br /> Name of Business: I�-c� Z GQti� <br /> Contact Person: S Telephone: ) 7- <br /> Physical Address: Z <br /> Mailing Address: P•� . r��is t� 1pAt r� Cl S zy-I <br /> E. DESCRIPTION n <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: i bz <br /> F. ACTION TAKENS-PuvyCe 5;� �i nlr Q /lpaN �p <br /> SITE DISPOSITION �� Glgyhe_e �� 3 iYb�Q <br /> EH 22 013 (Rev.4/91) <br />