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i� SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> Health h Safety Code 4 25180.1 <br /> A. EMERGENCY LEVEL: II III Health District Log I 'T!r' <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Original Source: Telephone: `)15�/—���/ <br /> Reporting Agency Name: <br /> Agency Contact: Telephone: O�') <br /> Address: K � <br /> C. LOCATION MD DATE OF DISCHARGE Date of Discharge:���/y� <br /> Date Notified: Time: <br /> Location: %/ 4��Lll <br /> • Best Physical De pt n (City or ount <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 /> Chemicals: <br /> F. ACTION TAKEN <br /> oe <br />