Laserfiche WebLink
....A � .. ..ter' <br />SAN JOAQUIN COUNTY FE <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7 w <br />A. EMERGENCY LEVEL:I�I III PHS -EH LOG # <br />(Circle One) <br />B. SOURCE OF INFORMATION <br />Name: Phone: (2-) <br />Company: -� 3" • �°f S – �' <br />Address: <br />Designated Employee Name: Phone: (� <br />Reporting Agency Name: <br />Address: 41fI-5 Al 942n1 <br />C. LOCATION AND DATE OF DISCHARGE _ <br />Location:(Best Physical Physical Descn pti �) ( County) Circle One <br />Date of Discharge: NN ow <br />Date Notified: Z 9 Time: <br />A <br />RESPONSIBLE PERSON/BUSINESI <br />Name of Business: <br />Contact Person: <br />Person: <br />Physical Address: / Flo w/ <br />Mailing Address: '' <br />E. DESCRIPTION <br />Type of Discharge: <br />Volume: art k <br />Chemicals: 4:574: <br />Circumstances: c <br />F. <br />Telephone: 4j <br />EH 22 013 (Rev -4/91) <br />