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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HEALTH &��DO80ISCHARGE <br /> HCODE 251 <br /> A. EMERGENCY LEVEL: (� 11 111 PHS-EH LOG # <br /> Circle One) <br /> B. SOURCE OF INFORMATION �/ Telephone: <br /> Original Source: �RrC �rP�VENhf <br /> Reporting Agency Name: .S4N rl� Co. Pv�Lt NLS <br /> Telephone: ( Z_-t ) <br /> Agency Contact: SWF,l -7-X <br /> Address: zlg5 <br /> C. LOCATION AND DATE OF DISCHARGE STn�!<TDtI� <br /> Location: ;3Z 5 F( /JoR�$Do / or County) <br /> (Best Physical Description) (City <br /> Date of Discharge: " O to <br /> Date Notified: _/�-i!� <br /> Time: 67: 3o a <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business s nr�K-Mv T-tN <br /> Contact Person: lTelephone: <br /> p <br /> Zo8 Fl�r1 t GEY -�— <br /> Physical Address: A3 7S. t— ODA40 <br /> E. DESCRIPTION <br /> Type Release: <br /> 261 p.D A+OTbl2 V6111t,1,E �UEL <br /> Volume: NKNUc.>ri/ <br /> Chemicals: 6A90G! E �QOdULT <br /> F. ACTION TAKEN <br /> So6� ,�265u�-TS FQv.�1 T,�rIK 12E�oV.�L zN�lc�TF — <br /> Sp <br /> EH 22 013 (Rev. 02/90) <br />