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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVELO II III PHS-EH LOG # mo <br /> ( Circle One) <br /> B . SOURCE OF INFORMATION <br /> Original Source: Telephone: �% ) 77 ./;S' <br /> Reporting Agency Name <br /> Agency Contact: Telephone: q <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location : <br /> (Best Physical De cription) (City or County <br /> Date of Discharge: 2 - / 9 ' 21 <br /> Date Notified: 15; - J Time: _ /Z : S q ,2 �J <br /> t • <br /> D. RESPONSIBLE PERSONBUSINESS <br /> Name of Business <br /> Contact Person: Telephone: 5:2/ -Z/SLf <br /> Physical Address: <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: <br /> Chemicals: <br /> F. ACT ON TAKEN <br /> i <br /> Joe <br /> EH VO � � ' <br />