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4 <br /> SAN JOAQUIN COUNTY FILE COPY <br /> D TIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> p GE <br /> 5 p2S HEALTH & SAFETY CODE 25180.7 - <br /> � Fi f <br /> A. EMERGENCY LEVEL: I I ) <br /> I One PHS-EH LOG #r. <br /> B. ., SOURCE OF INFORMATION—`- -_ <br /> Name: Phone: <br /> U � <br /> Company: : <br /> Address: 5 o r [ ..r' <br /> Designated Employee Name: Phone. ( <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: D E. <br /> (Best Physical.Descri tion) i r County) Circle One <br /> Date of Discharge: I A v-v <br /> Date Notified: U� Time. <br /> D. RESPONSIBLE PERSOP./BUS[ ESS <br /> Name of Business: oLC <br /> Contact Person:' -e-.5 O z Telephone: (2=-7 1— <br /> Physical <br /> 2 -71— <br /> Physical Address: © 12 n n i,:," S Q rri <br /> Mailing Address: <br /> E. DESCRIPTION . <br /> Type of Discharge: <br /> Volume: ►-` <br /> Chemicals• 5 - <br /> Circumstances: . . . b <br /> �L. 0 c_ f., <br /> F. ACTION TAKEN UST �'P.�-n_ o C <br /> SITE DISPOSITION C� i� ►Y. ,,,.� zc3 <br /> C .. <br /> EH 22 013 Re <br />