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SAN JOAQUIN CO t'A <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL(5 II III PHS-EH LOG # ( " Q <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Original Source: C�Q Q Q <br /> Telephone: <br /> Reporting Agency Name: 5,17 c01, t/617 <br /> Agency Contact:f`� ,,?a✓ f�� Telephone: <br /> Address: ,L 17 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: a <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: „4 l ez"/1l <br /> Date Notified: —0 Time: 3 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business <br /> Contact Person: a Svssrn�r� �i` Telephone: <br /> Physical Address: GYM ,S �� All, <br /> E. DESCRIPTION <br /> Type Release: a <br /> .�o Ex9 <br /> Volume: <br /> Chemicals: I��,✓��� z.?s <br /> F. ACTION TAKEN <br /> Nbw <br /> � y � <br /> EH 22 03 (Rev. 7/89) <br />