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J <br /> SAN JOAQUIN COUN'T'Y <br /> NO"IIFICt1TION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 Fly <br /> A. EMERGENCY LEVEL:J II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION .� <br /> Name: 6 Phone: <br /> Company: f <br /> Address: 14 33 <br /> Designated Employee Name: Phone: C__) <br /> Reporting Agency Name; s k <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE ' <br /> Location: [i5CD <br /> (Hest Physical Description) (City or County) Circle One <br /> Date of Discharge: <br /> Date Notified: - Ti- <br /> me.--fJAAA - <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Tele <br /> Physical Address- <br /> Mailing <br /> hone: <br /> S (` Cz) Z-O/voz� <br /> Mailing Address: <br /> E. DESCRIPTION .- <br /> Type of Dischar e: <br /> Volume: <br /> Chemicals: <br /> Circumstanc s: <br /> F. ANION TAKE <br /> SITE DISPOSITION <br /> a 0 — < <br /> EH 22 013 (Rev.4/91) <br /> _ - - 7 <br />