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ra <br />1.1 <br />SAN JOAQUIN COUNTY <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7 <br />EMERGENCY LEVEL:II III PHS -EH LOG # <br />(Circle One) <br />SOURCE OF INFORMATION <br />AT.mo• lm M O/tom Iki u <br />Company: <br />Designated Employee Name: < "c+ -- ✓ <br />Reporting Agency Name: <br />Address: c Us- /L" Sah j CF , <br />Phone:ao9 9 Y1 - 5-2 7,/ <br />Phone: 03 cl&J- - s v Ko <br />C. LOCATION AND DATE OF DISCHARGE �Cst « a <br />Location: /P33 f F fa S� /Gr � / c lch <br />(Best Physical Description) i r County) Circle One <br />Date of Discharge: <br />Date Notified: ///G� lg 2 Time: a �m <br />D. RESPONSIBLE PEI <br />Name of Business: <br />Contact Person: _ <br />Physical Address: . <br />Mailing Address: _ <br />E. DESCRIPTION <br />Type of Dischz <br />Volume: <br />Chemicals: 7. <br />Circumstances <br />F. <br />Telephone: ( ud sa / 2 <br />w <br />M <br />EH 22 013 (Rev.4/91) <br />