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• SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE rw <br /> HEALTH & SAFETY CODE 25180.7 "`��� <br /> A. EMERGENCY LEVEL:CI II III PHS-EH LOG # /I(J V <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: - 'I' Phone: 94-Z.1 <br /> Company: LOS <br /> Address: <br /> Designated Employee Name: Phone: ) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISC GE <br /> Location: j I w , <br /> (Best Physical Description) (City r County) Circle One <br /> Date of Discharge: C/ — 1� q 7 <br /> Date Notified: T—i C_ c! 7 Time: �f <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: �S �} � 7,� 1�� Telephone: <br /> Physical Address: <br /> Mailing Address: P, O Ox <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <� <br /> Chemicals: 3— <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE D[:S�POSITIO�NC <br /> ,4 <br /> Y�7 ` iLv� <br /> U <br /> EH 22 013 (Rev.4/9 i) <br />