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�. 0' <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180 . 7 <br /> A. EMERGENCY LEVEL:(0 II III <br /> (Circle One) \ HEALTH DISTRICT LOG # -d 9 <br /> B. SOURCE OF INFORMATION <br /> Original Source: L lam" JL"C- �PS G� Telephone: ( ) �(0�-.3-11j0l <br /> Reporting Agency Name: <br /> Agency Contact: -1-7` oft 2��,� <br /> Telephone: <br /> Address: NP o / F1`-lJYt�I lm /4 �5 o�C� I <br /> C. LOCATION AND DATE OF DISCHARGE F � <br /> Location: <br /> (Best Ph sical �escription) (City oounty)y D D 7''IQYA C y <br /> Date of Discharge: 4-1 <br /> Date Notified: �1��/� I/ 36 <br /> Time <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business <br /> Contact Person: 011 <br /> Telephone: (�f6C) <br /> Physical Address: oA 0�0M� � . <br /> n� <br /> E. DESCRIPTION <br /> Type Release: <br /> Volume: <br /> Chemicals: <br /> F. ACTION TAKEN D <br /> dw <br /> `�- 1D n <br />