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SAN JOAQUINCOUNT Y <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVELe II III PHS-EH LOG# <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company: ✓ 5 y <br /> Address: t 1 d _ <br /> Phone: <br /> DesignatedEmplo}•eeName: A i• � IY lel 16Y� <br /> Reporting Agency Name: n ^ A / — GfDl CfSZOZ <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: (012 W 6l " <br /> (Best Physical Description) i r County) Circle one <br /> Date of Discharge: LkyL- ern <br /> t Time: <br /> Date Notified: <br /> D. RESPONSIBLE PERSONBUSNESS <br /> Name of Business: ZA Pho/n�e:�Q�83�i—g3a <br /> Contact Person: `7S8'!(O <br /> Physical Address: �� vv <br /> Mailing Address: D <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: MQr- Arne U„P Qn p Qln$I lsQ✓1�1f1J�2- <br /> Chemicals: IC OA(rte. , : 4o I <br /> Circumstances: rKILO- -L t <br /> F. ACTION TAKENS r -6 LA;Vn9L <br /> Y <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.08/20/98) <br />