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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180,7 r ` <br />! U 1 <br /> I <br /> A. EMERGENCY LEVEL: ( I/ II IIi HEALTH DISTRICT LOG <br /> (Circle One) LL// <br /> B. SOURCE OF INFORMATION # <br /> Original Source: Telephone: (2�1) <br /> Reporting Agency Name: - <br /> Agency Contact: �� �y�/IATelephone: (.�ugj ) <br /> Address : (oG G Ii4 L1 f�21c. X5-20 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Description) (City or County) E <br /> Date of, Discharge: ,1 C , n ` <br /> Date Notified: -2k'c Time: , C& c, <br /> d l - I <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business .- _/ TO_CSc_7-7-1 <br /> Contact Person: f� � r <br /> /rig:%� Telephone: <br /> t <br /> Physical Address: C,/ <br /> E. <br /> E. DESCRIPTION <br /> Type ke.lcase: <br /> - _ <br /> Chemicals : <br /> I'. <br /> ACT 14So 'P KLN <br /> f Z t." i •cel k ' G' l 1 <br /> " I <br /> r <br /> t <br /> 'a <br /> i' ' <br />