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i <br /> SAN JOAQUIN COUNTY O O <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHAR <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Original Source: Telephone: ( _� <br /> JILL "'lbr <br /> Reporting Agency Name: 5L-z2 22-24'L— <br /> Agency Contact: �?a —y/ a,?— Telephone: Daf, <br /> Address: /6631 C.4 9-s--20/ <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: d 510/ zs />?a r,/eCa C� <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: <br /> Date Notified:Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business <br /> Contact Person: ��C/trzPs C'. 7/v�r��s Telephone: <br /> Physical Address: <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: <br /> Chemicals: <br /> F. ACTION TAKEN l- <br /> e zz;/� ,-4e- ae c e's S LY r c/ O �'�.� �• P <br /> EH 22 03 (Rev. 7/89) <br />