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r � <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> 11F�kLTH & SAFETY CODE 25180.7 <br /> , <br /> PHS-£H LOG _L_ 3 <br /> P,. EMERGENCY LEVEL: I� II III <br /> (Circle one) <br /> B. SOURCE OPrNFORytATION NT <br /> Name: r Phone: (z&D S'2'Z CZ c?exp -- <br /> Company: <br /> Address: 1'- ' <br /> Designated Employee Name-. Phone: <br /> w Reporting Agency Name:4n j- <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE ... <br /> Location: I oo <br /> (Best Physical Description) ( o County) Circle one <br /> : r Date of Disc, ge: <br /> Date Notified: z3 Time: <br /> _ i <br /> D. RESPONSIBLE PERSONIBL'SINESS a, <br /> Name of Business: <br /> Cont�ctPerson: Phone: �`t g�S" <br /> Physical Address: r, <br /> viailing Address: O `G <br /> E. DESCRIPTION ; <br /> - r i <br /> r Type of Discharge: <br /> Volume: c <br /> Chemicals: x <br /> e <br /> Circumstances: ETA Q Y-C1t,1LjA 10 JA <br /> �. <br /> F_ ACTION TAKEN Y r 1 <br /> ;SITE DISPOSTI`ION -t L•� <br /> f <br /> EH 22 013 (Rev.43/_4/98) ` <br />