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._� SAN JOAQUIN COUNTY <br /> NOTIPY,eATION OF HAZARDOUS WASTE DT-J'CHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL.0II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: r lYl Phone: &a) <br /> Company: <br /> Address:_ o i,c <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: qa 0 0 ly A-&�-Y\, L.J „ <br /> (Best Physical Descri tion) (City o oun Circle One <br /> Date of Discharge: � <br /> Date Notified: I c) �,-7 Time: f ( '00 -� <br /> D. RESPONSIBLE PERSON/BUSI�ESS <br /> Name of Business: L� - A . A— —, <br /> Contact Person: 7 Telephone: (z?to a -7 <br /> Physical Address: o c) <br /> Mailing Address: ! 5 S ( <br /> E. DESCRIPTION <br /> Type of Discharge: __ 7L <br /> Volume: 1 Al <br /> Chemicals: <br /> Circumstances: <br /> Z <br /> F. ACTION TAKEN «Jhn �, ,�-� cA �r•-v.�2 /1�,�-�z-�- <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.4/91) <br />