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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:�I II III PHS-EH LOG <br /> (Circle One) <br /> B. SOURCE OF INFO RMAT <br /> ON <br /> Name: Ph ne: o?( a9) <br /> Company <br /> Address: 30FS 614 9 <br /> Designated Employee Name: Phone: <br /> Reporting A$ency Name• Leo / ' .Sri lljp} <br /> Address: v 64kl 9 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: L�T Bhp <br /> (Best Physic Description) I or County) Circle One <br /> Date of Discharge1- 01P <br /> Date Notified: Zz Time: 9 DD AW <br /> D. RESPONSIBLE PERSON/BUSINESS . <br /> Name of Business: S <br /> Contact Person: l . Telephone: 7/ G-2 2 670 <br /> Physical Address: <br /> Mailing Address: r' a <br /> E. DESCRIPTION <br /> Type of Discharge- <br /> Volume: Z y��W-I- <br /> Chemicals: <br /> Circumstances: <br /> �cJ <br /> F. ACTION TAKEN <br /> c� <br /> SITE STATU r e <br /> EH 22 013 (Rev.4/91) <br />