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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: <br /> Name: <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: L� <br /> Reporting Agency Name- S?" <br /> Address: G{�f <br /> C. LOCATION AND DATE OFIS °}�GE <br /> Location: �• S <br /> (Best Physical Descrip •on) (City or County) Circle One <br /> Date of Discharge: <br /> Date Notified: <br /> l Time: <br /> D. RESPONSIBLE PERSON/BVINESS <br /> Name of Business: G/ <br /> Contact Person: T Telephone: �v <br /> Physical Address: y <br /> Mailing Address: - O• �o oc v �O�` <br /> i <br /> E. DESCRIPTION _ <br /> Type of Discharg <br /> Volume: /G w <br /> Chemicals: l%4 G <br /> Circumstances: <br /> _ <br /> eee,4 S �-V-V P <br /> F. ACTION TAKEN %NDL � _--- <br /> v h/i3'/93 <br /> SITE STATUS s F c <br /> B T <br /> EH 22 013 (Rev-4/91) <br />