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✓ SAN JOAQUIN COUNTY` ✓ <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVEL: (j—%II III PHS -EH LOG # <br />(Circle One) <br />B. SOURCE OF INFORMATION <br />Name: Phone: <br />Phone: <br />Company: <br />Address: i o'o C-oAcr/ ,c'.oA-, 4rc✓ r ac/ G/4 ��� �/<� <br />Designated Employee Name: Phone: yss -6 <br />Reporting Agency Name <br />C. LOCATION AND DATE OF DISCHARGE <br />Location: i 70o S Z'0_ <br />(Best Physical Description) <br />Date of Discharge: 6 i✓ Khlo wA 1 <br />Date Notified: 7!/_ _&FL <br />D. RESPONSIBLE PERSON/BUSINESS <br />Time: q.. w <br />(City or County) Circle One <br />Name of Business: 1/.1 PF_F�l2 /{ofr�s' fi✓G. <br />Contact Person: Telephone: L� <br />Physical Address: -7f0!-5 c%F <br />Mailing Address: 4:5:.4 �5 c <br />E. DESCRIPTION <br />Type of Dischz <br />Volume: Cis` <br />ces: <br />F. ACTION <br />SITE DISPOSITION F <br />Ta <br />EH 22 013 (Rev.4/91) <br />