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• SAN <br /> JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:�II III PHS-EH LOG # <br /> (Circle One) O <br /> B. SOUR4EF &eDv <br /> ON <br /> Name: � .Phone: <br /> CompAddres <br /> Designated Employeame. _ 5 Phone: �) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 57oq 7-'- F j k@tr <br /> (Best Physiqal Description) (City o Coun Circle One <br /> Date of Discharge: <br /> Date Notified: 11-5D-N Time: <br /> D. RESPONSIBLE PERSON/BUSIN SS <br /> Name of Business: <br /> Contact Person: Telephone: �) <br /> Physical Address: <br /> Mailing Address: l 0 1 (A�_� L 3 3 <br /> E. DESCRIPTION <br /> Type of Discharge: 0 <br /> Volume: <br /> Chemicals: <br /> Circumstance LA AK <br /> F. ACTION TAICIN <br /> Vyesl <br /> SITE DISPOSI ION A ,1A,(bl �al <br /> 141 <br /> I/ J <br /> I <br /> EH 22 013 (Rev.4/91) <br />