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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE (C(D [PS <br /> HEALT11 & SAFI-I CODE 25180.7 <br /> A. EMERGENCY LEVEL: 0II III <br /> (Circle Une) HEALTH DISTRICT LOG <br /> B. SOURCE OF INFORMATION <br /> Original Source: --r— I 1 . 1 1 <br /> Reporting Agency Name: \5 telephones.one: C 1UL �7 <br /> Agency Contact: <br /> Telephone: UZ2) <br /> Address: JEL3_v_yL, <br /> or <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Hest Physical Description) % Or County-) <br /> Date of Discharge: Scl <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINI:'.SS <br /> Name Of Business <br /> Te 1 e-P'4 0" (205 1 <br /> Physical Address : <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: <br /> Chemicals: <br /> P. ACTION TAKEN <br /> ....................................... <br /> 2 <br />