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.SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> I <br /> HEALTH & SAFr_T1t CGDE 251W . <br /> A. EMERGENCY LEVELO II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Original Source: <br /> Telephone: <br /> Reporting Agency Name: Stf4 <br /> Agency Contact: Telephone: - 3 `� d <br /> Address: p �' <br /> C. LOCATION AND DATE OF DI CHARGE i <br /> Location: <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: <br /> Date Notified: t Time: D 11 ,3 D Q� <br /> D. RESPONSIBLE P •RSON/BUSINESS <br /> Name of Business <br /> z <br /> Contact Person: Telephone: (2?62 ) <br /> Physical Address: , <br /> a� <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: L <br /> Chemicals: ` u <br /> F. ACTION TAKEN <br /> r - 2 LO <br /> � <br /> -cad, <br /> }� <br /> EH 22 03 (Rev. 7189) C�C <br />