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SAN JOAQUIN COUNTY P— )..f NOTIFICATION OF HAZARDOUS WASTE DISCHARGEC(D <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company: ; <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Description) (City or County) Circle One <br /> Date of Discharge: /- 2b - Yt _—•-- <br /> Date Notified: i- -,2,n- S Time: we �m <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 9—,v C <br /> Contact Person: m,_t Gin.rc ;n ic,6 Telephone: <br /> Physical Address: '?S'yo <br /> Mailing Address: ::f)A-y" _ <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: l <br /> Chemicals: c, <br /> Circumstances: r <br /> F. ACTION TAKEN <br /> SITE STATUS <br /> EH 22 013 (Rev.4/91) <br />