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- f - G <br /> SAKI JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL- PHS-EH II IiI PHS-EH LOG # 00 y <br /> ( Cie 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: . w 3cR) <br /> (Best Phyiical Description) <br /> (City or ottnry ° de One/ - <br /> Date of Discharge: / - / 7 -1 <br /> 7 <br /> Date Notified: _ - _Z—Z 7 —fj '7 - Time: //•' 3� <br /> D. RESPONSIBLE PERSON/BUSIN SS <br /> Name of Business: <br /> Contact Person: Telephone: (� <br /> Physical Address: <br /> Mailing Address:E. DESCRIPTION <br /> Type of Discharge: s <br /> Volume: -, <br /> Chemicals: <br /> - - <br /> Circumstances:��,t-f(. <br /> F. ACTION TAKEN 01n <br /> SITE DISPOSITION r <br /> EH 22 013 (Rev-4/91) <br /> JAN-21-1997 11:11 9?: p.IJ2 <br />