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i <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAzARDOUS WASTE DIS GEf <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: 1 II III PHS-EH LOG 9 3 —Qk-3 <br /> (Circle One) <br /> B. SOURCE OF I FOTIO <br /> Name: n Cc Phone: O -- 3 <br /> Company: <br /> Address: <br /> Designated Employee Name: -e f' ` Phone: o L n �` <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE A.0 66, <br /> Location- <br /> •(Best Physical Description) v �ty unty) Circle One <br /> Date of Discharge: r <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> . <br /> Name of : <br /> atct Person: Telephone: <br /> Physical Address. <br /> Mailing Addy . .S <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: ' <br /> Chemicals: <br /> Cir tances• <br /> , <br /> F. A ON tAKEN <br /> �v <br /> i <br /> 2G�c <br /> SITE DISPO ON <br /> c <br /> EH 22 013 (Rev.4/92) <br />