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SAN JOAQUIN COUNTY tr <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE (r n 7)y <br /> CD <br /> HE.-\L.TH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL II III PHS-EH LOG # — 3 <br /> ircle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: <br /> Name <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: (ZO!) Y6 -033 <br /> Reporting Agency Name: se"'Iccs — eD <br /> Address: Li L S SG o- �:.� Sl—• C� �SZO/ <br /> C. LOCATION AND DATE OF DISCHARGE ` <br /> Location: 3 z,__0 S• S�\c.A-�= ^ / <br /> (Best Physical Des=Ddon) or County) Circle One <br /> Date of Discharge: ,�� ^ <br /> Date Notified: -/y=.5;y Time: <br /> D. RESPONSIBLE PERSON/ US2NESS l <br /> Name of Business: / <br /> Contact Person: 1.1 Telephone: (22D—S-22 • y z 6 <br /> Physical Address: 37-ca S. Sic <br /> Mailing Address: P o a ,r ` a.•1 C f� 6 t <br /> E. DESCRIPTION <br /> Type of Discharge: LA <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN <br /> �✓as r vzt�- � �. <br /> SITE STAT S Fn <br /> EH 22 013 (Rev-4/91) <br />