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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE ! <br /> HEALTH & SAFETY CODE 25180.7 I <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> i <br /> Original Source: ' lil Telephone: _ ) <br /> Reporting Agency Name: - ' - 'S <br /> Agency Contact: Telephone: 3 S <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: y !y� 1 c:�s L V_ _ . I �' <br /> (Best Physical Description) il (City or County) <br /> Date,of Discharge: N <br /> Date Notified: O Time: Zn <br /> D. RESPONSIBLE PERSON/BUSINESS !! <br /> Name of Business <br /> Contact Person: !N 'I�Telephone: .?o ' '} O i <br /> r <br /> Physical Address: ` <br /> E. DESCRIPTIO <br /> I <br /> Type Release: <br /> Volume: <br /> Chemicals: <br /> F. ACTION TAKEN <br /> ri <br /> C <br /> c L_ <br /> S <br /> EH 22 03 (Rev. 7/89) . <br />