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• SAN JOAQUIN COUNTY • <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 i � '\v� <br /> A. EMERGENCY LEVEL: 1)11 III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION . <br /> Name: M t k6 � iZ 5 S t Phone: <br /> Company: Cy �"S <br /> Address: <br /> Designated Employee Name: F ✓ G Phone: (Zi:M <br /> Reporting Agency Name: <br /> Address: { /' C >C o <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: // Sr -3 0 z,&I ? lywle <br /> (Best Physical Description) (City or Counry) Circle One <br /> Date of Discharge: <br /> Date Notified: 6 — Time: 1 v <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: /'�V d <br /> Contact Person: Telephone: 52- <br /> Physical Address: <br /> Mailing Address: Sin and <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: a v <br /> r". ACTION TAKEN <br /> G <br /> SITE DISPOSITION F7 44 A, C P a <br /> OC'S51 �� G/eGc N^ <br /> T r'� ✓2,e . <br /> EH 22 013 (Rev.4/91) <br />