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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> !r . HEALTH 6 SAFETY CODE 25180. 7 <br /> A. EMERGENCY LEVEL: II II III HEALTH DISTRICT LOG N �QOS✓ <br /> (Circle One) <br /> B. SOURCE OF INFORMATION � � <br /> ng� <br /> Original Source: zat� ( 1�. /Telephone: Q,O7 ) 1/683V2O <br /> Reporting Agency Name: S• , t. 14 D . -id. <br /> Agency Contact:/a44.� � u �[i;� Telephone: O g•�yLO <br /> Address:��/, <br /> C. LOCATION AND DATE <br /> //OF DISCHARGE <br /> Location: .Ll�/. S.S <br /> (P.est Physical Descripti (City or County) <br /> Date of Discharge: �/( jy ply <br /> Date Notified: (/�� Time: -"90 P14, <br /> i <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business (jGZt(' P <br /> Contact Person: lidC Telephone:( ) <br /> Physical Address : <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: / <br /> Chemicals: <br /> F. A�,TION TAKEN <br /> /-//+ {4 <br />