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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVE III III PHS-EH LOG <br /> ircle One) <br /> B. SOURCE OF INFORMATIO <br /> Name:L_C'-- ! qq Phone: Cid) Y <br /> Company: <br /> Address: <br /> Designated Employee Name: r Phone: Gaq-6,V <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: -3/.5 /�2 a <br /> (Best Physical Description) C��r County) ircle One <br /> Date of Discharge: u�r�Fie2c4 i•i1-yC/ <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON BUSINESS <br /> Name of Business: G . �G <br /> Contact Person: Telepho b-,;�l <br /> Physical Address: 4 _ _ rrZ <br /> Mailing Address: Sm ane <br /> E. DESCRIPTION <br /> Type of Discharge: 1` eyW+-P 61 felt& . <br /> Volume: <br /> Chemicals: <br /> Circumstances. =� <br /> F. ACTION TARN <br /> NIJ <br /> Os <br /> L.G <br /> i <br /> SITE STATUS <br /> EH 22 013 (Rev.4/91) <br />