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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 �(`vJ)) fpy <br /> A. EMERGENCY LEVEL:/ I JII III PHS-EH LOG # / -a b 7 <br /> Cie One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: L� <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: eo Ca <br /> Address: -34 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: -7,3 `( /-J / <br /> (Best Physical Description) (City or un Circle One <br /> Date of Discharge: .4 -/7 -er.b <br /> Date Notified: / / 6 Time: // ;,Uzpm <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: Cdr Fr ,r, <br /> Contact Person: /�� r1 r ry a�/L, Telephone: C__3 <br /> Physical Address: -g,3 x' 7y-E7-,, L cj. 4E4 � 426 <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: - <br /> Volume: <br /> Chemicals: <br /> Circumstances: ti <br /> F. ACTION TAKEN P P = c <br /> SITE DISPOSITION �m o Iw w <br /> EH 22 013 (Rev.4/91) <br />