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too") <br /> SAN JOAQ <br /> U N COUNTY <br /> �. <br /> NOTIFICATION OF I HAZARDOUS WASTE DISCHARGE A D <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: Qui I <br /> III PHS-EH LOG # �v <br /> (Circle One) <br /> { <br /> B. SOURCE OF INFORMATION <br /> Name: ��ri �"P _ Phone: C )) ¢35 <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: ( ) <br /> Reporting Agency Name: <br /> Address: 3 �- f3F -i4•� VA12 gamt�L <br /> C. LOCATION AND DATE O DISCHARGE <br /> Locatio ?� S' Gni <br /> n• <br /> (Best Physical 'pdoT) ( r County) Circle One <br /> Date of Discharge:. v <br /> Date Notified: Tuue: Z;'D. RESPONSIBLE PERSQNBUSINE S . <br /> Name of Business: , <br /> Contact Person: Telephone:'() 3&fF- <br /> Physical Address: ZIZt;, Ok- Gvar .4E�It5. <br /> -- Mailing Address: <br /> I <br /> E. DESCRIPTION <br /> Type of Dis : <br /> volume: 1 <br /> Chemicals: E <br /> Circumstances: <br /> F. ACTION TAKEN <br /> I <br /> SITE DISPOSrIONIr <br /> E <br /> EH 22 013 (Aev.4/91) <br />