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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180 .7 <br /> LIA <br /> A. EMERGENCY LEVEL: II III HEALTH DISTRICT LOG # �/ � ` U <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Original Source: QA-.) /IiIQ,6jL1_ Telephone: LI <br /> Reporting Agency Name: /�i21C r <br /> Agency Contact: Telephone: (271' ) `fY Z <br /> Address: Z 4 .&OY - -206 5 d'h- fz- Zez <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: ,-:L 3 3 /U- A0 IW, . V Ot <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: '_ fJiV�i�Ldkl�J <br /> Date Notified: �6 y Time: -QU <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business 4 <br /> Contact Person: Telephone: (20� ) !6,? <br /> Physical Address: <br /> 1 d cC/�tJ <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: <br /> Chemicals: <br /> F. ACTION TAKEN <br /> - <br /> t11 <br />