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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY I EVEL: III III HEALTH DISTRICT LOG # C)G�� <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Original Source: �/� �y,//� Telephone: (2� ) <br /> Reporting Agency Name: ��� ✓o�fv�/��i ��� �� <br /> Agency contact: C /•� - <br /> ��i� - Telephone: <br /> Address: A0/ �71ZEL/C�� � �1 �-, �"Z �s <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: (Best Physical Physical Descrip ion) (City or County) <br /> I I r <br /> Date of Discharge: <br /> Date Notified: - �� r�-�� Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business <br /> Contact Person: Telephone: <br /> Physical Address : <br /> l.. 1)L:SCRI PTI ON <br /> '1'Yi,)e Re lease: <br /> Volume : <br /> C h em i c a Is : <br /> 5 0 <br /> aae4v- _ /c,� s- <br /> 712P �y <br /> C <br />