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t <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE J <br /> HEALTH & SAFETY CODE .. 25180. 7 cc <br /> A. EMERGENCY LEVEL:� II III <br /> (Circle one) HEALTH DISTRICT LOG # f - c')o <br /> B. SOURCE OF INFORMATION <br /> Original Source: w-lm - <br /> c Telephone: <br /> Reporting Agency - Name: <br /> Agency Contact: Telephone: . (P2) ��y <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> {Best Physi(yA1 + Description ) /{Cit or Countyr) <br /> Date of Discharge: _ [� <br /> Date Notifies]: <br /> . <br /> Time: - :SCJ <br /> U. RESi'ONSLBLE PERSON/BUSINESS <br /> Name of Business <br /> Cuntac:t Person: 11I6llJct2� �a� Telephone: <br /> PhYsic:al Address: 58Z/ <br /> E::. DE'SC:RI1''1'1UN <br /> Type <br /> vo l unle : <br /> Cl 1(2111i Ca I s : <br /> F. ACTION TAK1;N <br /> �' T �[/i� C.� �� �/�✓ifs/�?-C� <br /> k . <br /> a <br />