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C SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> �. E <br /> A. EMERGENCY LEVEL6I II III PHS-EH LOG # ` I <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Phone: <br /> Name: <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: ) R-3 <br /> (;M) <br /> Reporting Agency Name: aD "�0 " k <br /> Address: D j <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: C a- / <br /> (Best Physical Descri ) Ci or County) Circle One <br /> Date of Discharge: i I <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: ' - <br /> Contact Person: $2 Telephone: <br /> Physical Address: ` <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: - <br /> Volume: <br /> , <br /> Chemicals �-�- <br /> r <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE STATUS - T cie-c ` <br /> C -767 <br /> � <br /> UU <br /> EH 22 013 (Rev.4/91) <br />