Laserfiche WebLink
sftsw SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 C p <br /> r <br /> A. EMERGENCY LEVEL: (IJ II III PHS-EH LOG #_ <br /> (Circle One) <br /> B. SOURCE OF INFORM TION _ <br /> Name: r _t. c ••� <br /> Phone: <br /> Company: <br /> Address: r3 C'y- Q/ <br /> Designated Employee Name: Phone: ( ) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION 4ND DATE OF DISCHARGE e <br /> Location: ! 1w f.��,- C � / ( 4L't <br /> (Best Physical Description) (City or County) Circle One <br /> Date of D's charg : ✓�✓ <br /> Date Notified:s Jyl i Time: <br /> D. RESPONSIBLE PERS� BUSINESS y <br /> Name of Business: / 1?17��,��.,ic-L. <br /> Contact Person: Telephone: CItL�) CkS-7 7i <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstance : <br /> F. ACTION TAKEN <br /> SITE STATUS 'it,v ' S , ��L!� <br /> v[/i'...['%y✓/7.fit./L V4/�'� (/'.T ! ''��//t�3'"l�`ni'Z--(�. <br /> EH 22 013 (Rev.4/91) <br />