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i <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISC GE <br /> HEALTH & SAFE ODE 25180 7� <br /> j <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: �►! ' <br /> Company: Aerskqd <br /> Address: Z=LF <br /> Designated Empl a Name:,( �'� Phone: (K6Z) a33 <br /> Reporting Agency Name: xrot s (:�e;d <br /> Address: .. <br /> II <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: ,3R Q2 _ W,- <br /> (Best Physical Description) Ci or County) Circle One <br /> Date of Discharge' <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS k <br /> Name of Business: ' <br /> Contact Person: Telephone: (gW -�4- <br /> Physical Address: oei <br /> �a <br /> Mailing Address: .,,._ <br /> E. DESCRIPTION <br /> Type of Discharge: i <br /> Volume: _�10 <br /> 2'� _ <br /> 3 Chemicals: ..,... <br /> Circumstances: <br /> F. ACTION TAN <br /> i <br /> ' yy <br /> i <br /> I <br /> SITE DISP SI ION Dl AS CM0r c o <br /> { l <br /> EH 22 013 (Rev.4/92) <br /> 4 <br /> . 1 <br /> 1 <br />