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SAN JOAQUIN COUNTY D <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE ,, <br /> )y <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: CMI III PHS-EH LOG # �s 07-7 <br /> (Circle One) <br /> B. SOURCE OF Y4FORMATION <br /> Name: Phone: 7—,3q76 S, <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: /Fr 17) - l-1 / <br /> (Best Physical Description) (Cit�/or County) Circle One <br /> Date of Discharge: /Z'� <br /> Date Notified: 6 — % S-- Z 5 Time: �2—'.3 0 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: C2 >; Sr, Y-, Teleph ne: �1=31 Cyt <br /> Physical Address: 1 D 5.r Q <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: 4t-4—r7 , <br /> Chemicals: <br /> Circumstances: .ct.` r L Z' <br /> ` ,o <br /> F. ACTION TAKEN <br /> � e <br /> r <br /> SITE STATU <br /> EH 22 013 (Rev.4/91) <br />