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SAN JOAQUIN COUNTY r. <br /> NOTIFICn ION OF HAZARDOUS WASTE DISO.TARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: c ro Phone: <br /> Company: Y <br /> Address: 4-1 r 2 , a .,t_.. <br /> Designated Employee Name: 11 444::j Phone: QP 9 -5d <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 4, )OSc_- <br /> (Best Physical Description) LCit T or County) Circle One <br /> Date of Discharge: <br /> Date Notified: /D'-a! � � / Time: �3 .3 G o Yzu <br /> D. RESPONSIBLE PERSOI�BUSINESS <br /> Name of Business: <br /> Contact Person: -2 a Telephone: �/ oQ 63 -- / <br /> Physical Address: > 3 ) <br /> Mailing Address: 5 n <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: hazve6tb e--/ <br /> � o a <br /> F. AMO 1 TWICEN G <br /> SITE DISPOSITION 77- <br /> EH 22 013 (Rev.4/91) <br />