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wEy <br /> SAN JOAQUIN COUNTY <br /> Y <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE; <br /> HEALTH & SAFETY CODE 25180.7 <br /> 5 <br /> HEALTH DISTRICT LOG ` 00�.� <br /> A. EMERGENCY LEVEL. II III H4 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION ' <br /> i <br /> Original Source: ll'r4G r ! L Telephone: ( y )7 <br /> Reporting Agency Name: l �u <br /> Telephone:Tele { ) <br /> Agency Contact: p ---� j <br /> Address: 21 1r <br /> C.. LOCATION AND DATE OF DISCHARGE <br /> Location: 100 U-). CO / <br /> (Best Physical Description) (City or County) <br /> Date of Discharge: riewkmL <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business "- ; <br /> Contact Person: Telephone: ( ) S3S63o� <br /> Physical Address: `� � 2 <br /> f <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: h_( � <br /> if r <br /> Chemicals : <br /> F . ACTION TAKEN <br /> L t a fir; <br /> f2 <br /> '' <br />