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%apef <br /> 1i 1 <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: qI II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION p <br /> Original Source: Telephone: (jz,� ) � <br /> Reporting Agency Name: - ' - _� -5 <br /> Agency Contact: rzc - _ Telephone: V6 - 3 <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: �6 S�,�r�__) V.,!!F- _ 1 Z A <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: <br /> Date Notified: Time: <br /> �/, ` �_ Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business - - <br /> n <br /> Contact Person: 2 Q(Telephone: o?o C <br /> _ `� ��,� <br /> r <br /> Physical Address: <br /> E. DESCRIPTIO <br /> Type Release: <br /> " .' ' CV� Cin <br /> Volume: <br /> Chemicals: 0,,q5 0 <br /> F. ACTION TAKEN <br /> C1.1 <br /> G <br /> CON ef= <br /> EH 22 03 (Rev. 7189) <br />