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SAN JOAQUIN COUNTY Dy <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY'CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <br /> ( cle One) <br /> B. SOURCE OF INFORMATION <br /> Name: S Phone:1(2t <br /> Company: <br /> Address: <br /> Designated Employee Name: -6 Phone: Wd),''�/n�� -3 f Z,Z <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Description) , OC�rounty) Circle One <br /> 3 <br /> Date of Discharge:. . <br /> Date Notified: Time: [ <br /> D. RESPONSIBLE PERSO BUSINES <br /> Name of Business: <br /> Contact Person: Telephone: ( `� Z( <br /> Physical Address: <br /> Mailing Address: f} <br /> E. DESCRIPTION <br /> Type of Discharge: zz 14 2 , <br /> Volume: s v <br /> Chemicals: <br /> Circ Lances: <br /> F. Al ON TAKEN <br /> 1 <br /> S E TUTUS <br /> EH 22 013 (Rev.4/91) <br />