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SAN JOAQUIN. COUNTY [Py NOTIFICATION OF HAZARDOUS WASTE DISCHARG <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL.01 11I PHS-EH LOG #___ <br /> (Circle One) -` <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: L� <br /> Company: ' <br /> Address: "O *�- Avg Sa flEf p� �o e 15�fy�� <br /> Designated Employee Name: I Phone: �) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: P-04Z <br /> (Best Physical Descriptio (Cii or County) Circle One <br /> Date of Discharge: <br /> Date Notified: 101411-7e-1 e: 10%' <br /> D. RESPONSIBLE PERSON/BUSINES� <br /> Name of Business: <br /> Contact Person: -T/6-1 I Telephone: <br /> Physical Address: dfl j c 4 ���;fE? <br /> Mailing Address: __ /elrw v��©� .. ..�t� ,.�i��p <br /> E. DESCRIPTION <br /> Type of Dischar e: . ,^:.-n-4 <br /> Volume: ; r <br /> Chemicals: I <br /> Circumstances: i <br /> F. ACTION TAKEN`/ -Y �" r ,Q <br /> SITE STATUS <br /> I 10 11 <br /> I <br /> EH 22 013 (Rev.4/91) <br />