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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> Health & Safety Code § 25180.1 <br /> A. EMERGENCY LEVEL• I II III Health District Log / <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Original Source: / Telephone: <br /> Reporting Agency Name: <br /> Agency Contact: z., Telephone: (222) Sly 3Y13 <br /> Address: AGO <br /> Xg <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Date(s): ,/0-22— �l� Time: <br /> Location: ) <br /> { estPhysical Description) y orCounty) <br /> �t <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: <br /> Physical Address: > <br /> E. DESCRIPTION <br /> Type Release <br /> Volume: <br /> y . <br /> Chemicals: <br /> F. ACTION AKEN <br />