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Fly <br /> SAN JOAQULN COUiiTY v <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25I80.7 <br /> A. EMERGENCY LVEIa <br /> £ II III PHS-EH LOG T _00 �- <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Name: �1 alof <br /> N Phone: { � 4 <br /> Company: <br /> Address: #Emptloee <br /> Designate %N1 Phone: 3 <br /> Reporting Age cy Name: <br /> A 2111 <br /> Address: �D L <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location:'_ <br /> (Best PAysical Descption) i r Count') Circle one <br /> Date of Discharge: IIVV <br /> Time. I (�l z3Z� ! -tl'� <br /> Date Notified: <br /> D. RESPONSIBLE PERSON/BC;SNESS <br /> Name of Business: Lkl] <br /> Contact Person: �� L" Phone:�G _ _ <br /> Physical Address: . <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION T.-VKEN AT-) <br /> S 11� r L3 <br /> W 1 T 6 2-_ <br /> 9 <br /> Q?1 <br /> SITE DISPOSITIO <br /> � � r <br /> EH 22 013 (Rev. 08!20!93) <br />