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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL- <br /> I I III PHS-EH LOG # 26 -067 <br /> cle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: �) <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name:_�. c.�n. <br /> Address: —3o / <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 2,62 �( ✓�� a / vv► <br /> (Best Physical Description) (City or un Circle One <br /> Date of Discharge: — y <br /> Date Notified: j ti Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: -Fi7l rm '�!aWV?cA <br /> Contact Person: t4 r_ ('v.�[,g Telephone: �) <br /> �... Physical Address: Ta wf 2r„ 1—s 4 If- ! w` . <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: S.0 r-# ek =a ,.,- 4.M <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.4/91) <br />