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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> Health 5 Safety Code 4 25180.7 <br /> -`I 1I III Health District Log a <br /> LEYELG <br /> A. EMERGENCY j <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Original Source: Telephone: <br /> t <br /> r <br /> Reporting Agency Name: <br /> Agency Contact: <br /> Telephone: ) <br /> Address: <br /> s' <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Date(s): ,/D- 2— Time: � ow <br /> _� <br /> Location: or aunty <br /> r (Best s ca scr pt on y <br /> 0. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: (�� .• <br /> Physical Address: 2 <br /> E. DESCRIPTION - -�--- <br /> Type Release:Volume: <br /> Chemicals: <br /> F. :ACTION AKEN <br />