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1�d <br /> SAN JOAQUIN COUN'T'Y <br /> ,i NOTIFICATION OF HAZARDOUS WASTE DiSCEIARG l � I <br /> 4 HEALTHb SAFETY CODS; 25180 . 7 it:? V� - <br /> A. EMERGENCY LEVEL: II III <br /> € HEALTH One} EALTH DISTRICT LOG <br /> B. SOURCE OF INFORMATION <br /> Original Source: l <br /> Teephone: <br /> Reporting Agency Name: <br /> E� <br /> Agency Contact: <br /> i <br /> } { Telephone: Q22) <br /> h Address . <br /> C. LOCATION AND DATE OF DISCHARGE <br /> a Location : lof l �( y <br /> i <br /> + / <br /> (Best Physical Description ) (City or County) <br /> I� Date of Discharge.:.„- � <br /> Date Notified: <br /> Time: <br /> i <br /> D. RESPONSIBLE PERSON S <br /> /F3EJSINLS� � <br /> !I Name of Business <br /> k- <br /> Contact Person: ' <br /> jd� Telephone: ( 2_ef) <br /> 1 <br /> Physical Y l •r � � �TCAr, <br /> I)F•:SCR I PT ION <br /> F <br /> d j <br /> 'I'ypc Release: <br /> + <br /> ACTION TAKL•'ra • _ I <br /> !i I <br /> 3 11 R ( r 1rt <br /> ! <br /> o ifi{fi�l� <br /> f.' <br />