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V �...- <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180 . 7 <br /> A. EMERGENCY LEVEL: II III <br /> (Circle One) HEALTH DISTRICT LOG q g?j-ow <br /> B• SOURCE OF INFORMATION <br /> Original Source: <br /> Telephone: <br /> Reporting Agency Name: SS�r • <br /> Agency Contact: 4&AAze <br /> �' ��� <br /> ( Y/c: <br /> Telephone: <br /> 3�Cb <br /> Address: 1 (� p <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: —7!/ y <br /> (Best / <br /> sica Description) —(City or County) <br /> Date of Discharge: <br /> AV Date Notified: IaN/ ' <br /> Time: <br /> D- RESPONSIBLE PERSON/BUSINESS <br /> Name of Business <br /> Contact Person: <br /> Physical Address : -?(2 ��L�� � XL�C.Cuo'ti <br /> E. DESCRIPTION <br /> Type Releaser ale P) 4 GVIX�� 75S <br /> Volume : <br /> Chemicals : <br /> F• A "t`ION 'PAK6N <br /> / �-�1'1 k ✓'eA C, veu pec( <br /> CoA <br /> a��C <br /> C x <br /> ops <br />