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L <br /> SAN JOAQUL`i COL'NTY`� <br /> NOTIFICATION &S�O°COE s,8oS $�� E Copy, <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG.- O D • 049 <br /> (Circle one) <br /> B. SOURCE OF 1NFOR.N1-ATION <br /> Name: Phone: <br /> � <br /> Comp y: <br /> Address: Phone: <br /> Designate Emplovee Name: <br /> Reporting Agency Name: <br /> Address: vv <br /> C. LOCATIOi I AND ATE OF DISCI-DISCI-LARGE to <br /> �to C, <br /> Location: `I 6� 160 n nv r County) Circle one <br /> (Best Physical Descnpaon) <br /> Date of Discharge: IF,hBZ.A-: Time: <br /> Date notified: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: ��1 <br /> Phone: 2tx <br /> Contact Person: 0 <br /> Physical "Address: ' <br /> Mailing .address: <br /> in <br /> E. DESCRIPTION <br /> Type of Discharge: J✓ltlOr ( <br /> Volume: a <br /> Chemicals: _ 1 <br /> Circumstance ri <br /> F. ACTION TAKEN <br /> SID�DISPOSITIONy' <br /> s Y L P.t�F r 0}1 <br /> EH 22 013 Rev. 03/20/93) <br />