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,.� SAN JOAQUIN COUNTY ,� <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE COPY HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL0II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company- <br /> Address: <br /> ompany Address: <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address: e,-f,�,/ 4A -T2A©irrn s7- �Z <br /> C. LOCATION AND DATE OF pISC WE <br /> - <br /> Location: &L� N� '��r< <br /> (Best Physical Description) (City or �un Circle One <br /> Date of Discharge: nhKAJnu>A <br /> Date Notified: 6 3 Time: 9 oy t�z <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: o� GD,06 Telep ne: r'? <br /> Physical Address: 5::�-77 <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: GXfA�I A ZzF� <br /> Volume: <br /> Chemicals: <br /> Circumstances' <br /> F. A T QN GC ivy C/1 c7A <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.4/91) <br />