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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCfiARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL:III III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION Y6� jYG� <br /> ten/ o Phone: LRO <br /> Name: <br /> Company: — <br /> Address: <br /> Designated Employee Name: Phone: C.� Y68 2LG 1- <br /> Reporting Agency Name:_ .-u 6 /��/Z -a- <br /> Address• a <br /> C. LOCATION AND DATE OF DISCHARQE <br /> Location: C4 / G` (z- <br /> (Best Physical Description) iry County) Circle One <br /> Date of Discharge: <br /> Date Notified: ;,p-6 -9i Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 5-4; llwcc <br /> Contact Person: Telephone: (.2ca) yYY -S& 77 <br /> Physical Address: /io7 f <br /> Mailing Address: S <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: - <br /> Chemicals: X,/ H -G <br /> Circumstances: iS rsct r//G �>'� c l c f <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> nn.Lr -o aAPs/r t dL' co.�f�..` ! irJter.urir� 67, oc¢.O s-�ul�fi.T_ <br /> tog <br /> EH 22 013 (Rev.4/91) <br />