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SAN JOAQUIN COUNTY � (e-- <br /> NOTIFICAN OF HAZARDOUS WASTE DISC �.IGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> i <br /> A. EMERGENCY LEVEL:: II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: . / (-'U hs ) Sxc,--> Phone: (¢/6) 7S3-F c va <br /> Company C'✓ea/ c.Ls <br /> Address: V57A3 C'oc o/jz 2� �s 8iG <br /> Designated Employee Name: .n _ Phone: (Zai 34 `fD <br /> Reporting Agency Name: S ,�,' CD ,61 c 1.1v PC SQA kO c e c <br /> Address: yys nJ S,,' Li-oc g --4->-+ (A 9S.1U < RO./f-x dLi.a <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: in v v s, <br /> (Best Physical Description) ! (Ci or County) Circle One <br /> Date of Discharge: a<a/--�—O <br /> Date Notified: g/a7/gs Time: //Arn <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: A-1 <Fi� /�A h P/c<, 4/�5 <br /> Contact Person: L/z m Sc< /tTelephone: (20) 4166 -meq 7y <br /> Physical Address: <br /> Mailing Address: Ao.Box Y&y s/,3 e/—, rA 9 <br /> E. DESCRIPTION <br /> Type of Discharge: c..aaufti / <br /> Volume: <br /> Chemicals: GG 5ol�1P <br /> Circumstances: gl s A- ACs.. A /x-mVua0 LIP <br /> SSC �ff� <br /> F. ACTT ION TAKEN <br /> SITE DISPOSITION lCi-vllw s'/.r /o <br /> n�/_.� <br /> < 4 <br /> EH 22 013 (Rev.4/91) <br />