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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> Health & Safety Code § 25180.7 <br /> A. EMERGENCY LEVEL II III Health District Log # <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Original Source: Telephone: ( ) <br /> Reporting Agency Name: <-�—gn f6 4A;h LOC-0- ( <br /> Agency Contact: ,�_, (p�C4-1(01 Telephone: <br /> Address: , Q , X .(K) Q <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Date(s): Time: Stern <br /> Location: , <br /> Best PhysicalDe ription (City or C my <br /> D. RESPONSIBLE PERSON/BUSINESSS <br /> Name of Business: X r o <br /> Contact Person: Cc!` lu/Ci Telephone: <br /> Physical Address: <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: <br /> Chemicals: <br /> F. ACTION TAKEN <br />