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U V <br /> 1. SAN JOAQUN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE CCO <br /> HEALTH & SAFETY CODE 25180.7 <br /> _ U <br /> PHS-EH LOG <br /> EMERGENCY LEVEL: I II III <br /> (Circle One) <br /> SOURCE OF INFORMATION <br /> Name: �A Ann�»7�iC �Mrr JAI Phone: �Q� 57�-09DU <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: Q2. g' <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE / o <br /> Locadon: <br /> (Best Physical Des pilon) (City or unry) Circle One <br /> Date of Discharge: 6y"In <br /> Date Notified: ._) --A-9Time: :O D o � <br /> C). RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: Telephone: f�Q j�� _!a�C-/2! <br /> Contact Person: <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION # a <br /> Type of Discharge: <br /> PL - <br /> Volume: 4M <br /> Chemicals: _ <br /> Circumstances: - <br /> F. ACTION TAKEN <br /> a <br /> SITE DISPOSITION <br /> S e ss <br /> i <br /> f <br /> i <br /> I'- 'N 22 013 (Rev.4/91) <br />