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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARD06S WASTE DISCHARGE <br /> r HEALTH & SAFETY CODE 25180 .7 <br /> A. EMERGENCY LEVEL: I II III HEALTH DISTRICT LOG # <br /> ( Circle One) ` <br /> B. SOURCE OF INFORMATION <br /> Original Source: -- Ui��T _ Telephone: <br /> Reporting Agency Name: - _ ? <br /> Agency Contact: -Ziyr Telephone: { 20l) <br /> Address. <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: <br /> (Best Physical Description) (City or County) <br /> r <br /> Date of ' Discharge: <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business <br /> Contact Person: ry7 Telephone: (ZG`J ) 23J- <br /> k <br /> Physical Address : Ale <br /> U. DESCRIPTION <br /> Type I:elease: <br /> Volume: 3 <br /> C:l�c:m i c:a 1 s : r�r�.ld�,�''-' _��Q�?C�_.,�P�- •-•-- <br /> F. AC'CIUfJ 'CAK1:iJ �� 0�/S/�'l <br /> / !✓ C .G L G•n�� G{�.CEi'/i HCl c Ci <br /> Lj <br /> I <br /> L <br /> �y� <br />