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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE D[SCHARGE C n py <br /> HEALTH & SAFETY CODE 25180.7 V <br /> A. EMERGENCY LEVEL: I II III <br /> PHS-EH LOG # � � �G f <br /> ( cle One) <br /> g, SOURCE OF INFORMATION Phone: U <br /> Name: <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Naive: <br /> Address: 3u S_ <br /> C. LOCATION AND DATE OF DISCHARGE / <br /> Location: /z- ZQ i or County) Circle One <br /> (Best Physical Description) <br /> Date of Discharger n <br /> Date Notified: - // ::1 Time: o M <br /> D. RESPONSIBLE PERSON/BUUS�INESS <br /> Name of Business: 3 <br /> Contact Person: Telephone: (7�� <br /> Physical Address: ?5 <br /> Mailing Address: 7-3 _o <br /> F. DESCRIPTION _ <br /> Type of Discharge: <br /> Volume: <br /> Chemicals <br /> Circumstances: t^- <br /> F. ACTION TARN OP <br /> SITE STATUS r <br /> FH 22 013 (Rev-4/91) <br />