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G. MANDATORY CONTACTS San Joaquin County Environmental Health Department: (Contact Name) Tune) (Date) San Joaquin County (� \ Board of Supervisors: (Contact Name) (Time) (Date) H. HEALTH AND SAFETY CODE S 25180.7 (b)Any designated government employee who obtains information in the course of his official duties revealing the illegal discharge or threatened illegal discharge of a hazardous waste within the geographical area of his jurisdiction and who know that such discharge or threatened discharge is likely to casue substantial injury to the public health or safety must,within seventy two hours, disclose such information to the Board of Supervisors and to the local health officer. No disclosure of information is required under this subdivision when otherwise prohibited by law,or when law enforcement personnel have determined that such disclosure would adversely affect an ongoing criminal investigation, or when the information is already general public knowledge within the locality affected by the discharge or threatened discharge. (c)Any designated government employee who knowingly and intentionally fails to disclose information required to the disclosed under subdivision(b) shall, upon conviction, be punished by imprisonment in the county jail for not more tan one year or by imprisonment in state prison for not more than three years. The court may also impose upon the person a fine of not less than five thousand ($5,000) or more than twenty five thousand dollars ($25,000). The felony conviction for violation of this section shall require forfeiture of government employment within thirty days (30) of conviction. I. SIGNATURE DISCLOSURE I make this report on behalf of all the designated employees of the County of San Joaquin, and (Age6cy Name) Signature: Print Name: c Title: Date: Time: 2't�D ant. SITE CODE #: CC: Referred To: EHD 22-02.003 Notification of Haz Discharge 10/2/2003