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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE E E COPY <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III <br /> PHS-EH LOG# <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Name: C GhC. C . Phone: ( ) <br /> Company: <br /> Address:-W? <br /> Designated Employee Name, Phone. <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: �Z C L l — <br /> (Best Ph sical Description) C R or County) Circle one <br /> Date of Discharge: Time QQ' OS <br /> Date Notified: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: Phone: d2-$ <br /> Contact Person: wry, S nA /fir Jnr, <br /> Physical AddresIN .5• W <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge:VAAWZMWD <br /> Volume: <br /> Chemicals: <br /> Circumstances <br /> F. ACTION TAKEN ArjraC TU �iiurti <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.08/20/98) <br />