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SAN JOAQUIN COUNTY v <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE,;: <br /> HEALTH & SAFETY CODE. 25180.7 <br /> A. EMERGENCY LEVEL: I�)II III PHS-EH LOG # <br /> .cle One) . <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: ( � <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: (z E9 <br /> Reporting Agency Name: Sayl <br /> Address: 14Y E, <br /> C. LOCATION AND DATE OF DISCHARGE E` <br /> Ni <br /> I. <br /> Location. - o / <br /> (Best Physical Description) ( or County) Circle One <br /> Date of Discharge: r t1 n <br /> Date Notified: <br /> 1:c9 — Time: <br /> 'D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: a Telephone: CML <br /> Physical Address: <br /> i <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: �� <br /> Volume: n <br /> Chemicals: <br /> Circumstances: <br /> F <br /> ACTION TAKEN ^ <br /> SITE STATUS <br /> EH 22 013 (Rev.4/91) <br />