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u SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> C(D PID If <br /> A. EMERGENCY LEVEL:/I/II III PHS-EH LOG # <br /> ( ircle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (__j <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: Vb Lill <br /> Reporting Agency Name: S <br /> Address: Po g Or 38 n S'Fo C O+ R SZ-0( —0 3 <br /> C. LOCATION AND DATE OF DISC / <br /> Location: <br /> (Best Physical Description) (Ci o County) 'role One <br /> Date of Discharge: vt DI.L�n <br /> Date Notified: Time: 10:06 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: #v V Telephone: (� <br /> Physical Address- 13U9 lU 6 pr ne Ea CR 95-,�o <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: Ak 0 <br /> Volume ij A ww (> <br /> Chemicals: Q Sn I a e , <br /> Circumstances (Pya 'U Id( S MS <br /> F. ACTION TAKEN UC�-Ts Chi n DIAGP Lr�� w1 C�MGfP L-(A <br /> SITE STATUS S M to <br /> a -t, so, rn <br /> ,�a r s � <br /> EH 22 013 (Rev.4/91) <br />