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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE- DISCHARGE <br /> HEALTH . & SAFETY CODE 25180.7 <br /> <t <br /> A. EMERGENCY LEVEL: II III HEALTH DISTRICT LOG # -W2_ <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Original Source: — ,1.. Telephone: (2o-i ) ayo -s_72 l <br /> Reporting Agency Name: <br /> Agency Contact: Telephone: ( zo`% ) (I,.S- <br /> Address : ko- 1C <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: (Z�Lv tV.w <br /> (Best Ph sical Description) City or County) <br /> Date of Discharge: �(�IK�fiSr <br /> Date Notified: S in �Si� Time: IZ' <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business �yV <br /> Contact Person: .r�� �✓�a ;Ak', Telephone: <br /> Physical Address:.. l Z <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: <br /> Chemicals : d�e wed <br /> F_ ACITION TAKEN <br /> t 'e k Gq N'L�:J.., .7... S t�• �t� �S S'Q-S S h.:L�✓� <br /> COPY <br /> l <br /> .. c Y. <br />