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SAN JOAQUIN COUNTY <br /> NOTIFrt4mi'ION OF HAZARDOUS WASTE D[SCRARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVELdcle <br /> II III PHS-EH LOG # <br /> One) <br /> B. SOURCE OF I FORMATION <br /> Name: �orc( <br /> Company: Lr)hPPI�IOy/ Phone: <br /> U y, , <br /> Address: CoZ I PICt Ly �— <br /> Designated Employee Name. Phone: �) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: X29 S . etmn7efc, Strom /�f� <br /> (Best Physical Description) City r County) Circle One <br /> Date of Discharge: Cw--n lGi2C�uY <br /> Date Notified: - - (Z -E1 Z Time: <br /> D. RESPONSIBLE PERSOWBUSINESS /_ <br /> Name of Business: P t�oS� �rA,, <br /> i <br /> Contact Person: e / . • ,,,t, <br /> Physical Address: '755Z <br /> Telephone: ( )Z _ p�( <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: �j/� /y✓/ <br /> Volume: /min <br /> Chemicals: ¢ <br /> Circumstances: u Pd Gael <br /> /112!'Y�av-o,C <br /> F. ACTION TAKEN_ diyl�/ <br /> 51 E IS OSIT ON <br /> VL <br /> EH 22 013 (Rev.4/91) <br />