Laserfiche WebLink
SAN J'OAQUIN COUNTY `` ' + <br /> NOTIFLC.ATION OF HAZARDOUS WASTE LASCI RGE '. <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCYLEVEL: ( II III PHS-EH LOG # 5 <br /> (C�cle One) <br /> y <br /> B. SOURCE OF INFORMATION <br /> Name: c7r,I �'Ll- 4(1 J 1`C77rl rY�4 -P - - Phone: el(a ) - 3 <br /> Company: <br /> Address: c �_ rte. U Gf=)- -- <br /> Designated Employee Name: Phone: (__) <br /> Reporting Agency Name- <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE ! <br /> Location: <br /> (Best Physical Desc ' tion) orlCounty) Circle One <br /> Date of Discharge: I! <br /> Date Notified: Time: 0 ._ <br /> D. RESPONSIBLE PERS/BUS.INESS Il <br /> Name of Business: <br /> Contact Person: S Telephone: / . 7— <br /> Physical Address: � I� . <br /> I <br /> Mailing Address: _ 00 <br /> E. DESCRIPTION i <br /> Type of Discharge: <br /> Volume: IL la <br /> Chemicals: _ <br /> Circumstances: v►. ✓�- u-�� <br /> F <br /> r <br /> r II <br /> F. ACTION TAKEN ����'C2. GQi��b�Q�Cu� IfPfltit ,�PGX <br /> ' II <br /> `i <br /> I <br /> SITE DISPOSITION S. �� ei 3 -� <br /> 9 <br /> 0 <br /> EH 22 013 (Rev.4/91) <br /> �I <br />