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-' SAN JOAQUIN COUNTY /� D <br /> NOTIFICATION OF HAZARDOUS WASTE DISC E } , <br /> HEALTH & SAFETY CODE 25180.7 v j <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG #__ �O <br /> (Ci ,cle One) <br /> B. SOURCE OF INFORMATION <br /> Name: -r Go^Ez-- Phone: ",F- --p <br /> Company: © . eFF. S. <br /> Address:_2Z <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address: sA ���Qo v , s'::, s•�c��c7 c.¢- zo <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: ?cm -5- T0,4 Q u j, <br /> (Best Physical Description (City or C2n Circle One <br /> Date of Discharge: �r,l how <br /> Date Notified: i Time:. __S <br /> D. RESPONSIBLE PERSON/BU INES <br /> Name of Business: <br /> Contact Person: a w Telephone: 11-Wo w, <br /> Physical Address: <br /> Mailing Address: . ow <br /> E. DESCRIPTION , <br /> Type of Discharge: rii Ti �r � <br /> Volume: <br /> Chemicals: ____ <br /> Circumstances: <br /> i <br /> F. ACTION TAKEN -72:, /2�v <br /> SITE STATUS —/iS <br /> a t <br /> 4 1 <br /> 1 i <br /> EH 22 013 (Rev.4/91) �� <br /> { <br />