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SAN JOAQUIN COUNTY N—i <br /> NOTIFICATION OF HAZARDOUS WASTE DISn <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II <br /> III) PHS-EH LOG # <br /> (Circle One) <br /> B. SOURC OF INF RMATION <br /> Name: Phone: <br /> Company: <br /> Address: lb 1 F 2Z"- SY, <br /> Designated Employee Name: Phone: (_) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: PDO F 57k- -/ <br /> (Best Physical Description) City or County) Circle One <br /> Date of Discharge: 64-- -h- <br /> Date Notified: /2. - Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: K <br /> Contact Person: 4'/1/ Telephone: - .3af <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: _ <br /> Chemicals: <br /> Circumstances: <br /> s✓.eo. 6)6:� <br /> F. ACTION TAKEN__0 4*C6Zd <br /> - <br /> Y 1n F w su�iGCz <br /> SITE STATUS C <br /> L <br /> EH 22 013 (Rev.4/91) <br />