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SAN JOAQUIN COUNTY <br /> NOTIFIC,�MON OF HAZARDOUS WASTE DISCli!KRGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III <br /> PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION Phone: (._) <br /> Name: �- <br /> Company: <br /> Address: <br /> ne. <br /> Designated Employee Name: <br /> Reporting Agency Name: <br /> Address: �o E� - <br /> C. LOCATION AND DATE OF DISCHARGE / <br /> Location: ►a -� a.i t4 � �Coun Circle One <br /> (Best Physical Description) <br /> Date of Discharge: <br /> Date Notified: Time: �� oor <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: may --t� ��� I'r Y"r` <br /> Contact Person: �F-kr, -�-� Telephone: (. ) <br /> Physical Address: 1�-12 'S <br /> Mailing Address: C& 957-11, <br /> E. DESCRIPTION �`_ <br /> Type of Discharge: �ao.1 ate. �� � —14 <br /> Volume: <br /> Chemicals: <br /> Circumstances: 4- <br /> F. ACTION TAKEN V2e r n 'g:�d JIA <br /> A <br /> SITE STATUS C1 a.� a o << "'h ^' " <br /> --- - a� <br /> EH 22 013 (Rev.4/91) <br />