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SAN JOAQ�N COUNTY J SLE copy <br /> NOTIAO7ARDOOUSWESCEL <br /> T 25180.7 <br /> HEALTH & SAFE <br /> PHS-EH LOG 4 n <br /> A. E`IERGENCY LEVEL:(Circle one) <br /> B. SOURCE OF NFOR-'VLaTIO`1 <br /> Phone: ( ) <br /> Name: <br /> Company G�{/ <br /> Address: rnone. <br /> Designated Emplovee Name: <br /> Reporting ?Agency Name: <br /> Address: <br /> C. LOCATION A`ID DATE OF DISCI-LARGE Y <br /> i. /f th��— <br /> Location: t nor Couny) Circle one <br /> (Best Ph�,sical Descnpuon) <br /> Date of Discharge- <br /> Date <br /> ischarge Time: <br /> Date Notified: <br /> D. RESPONSIBLE PERSONBUSINESS <br /> Name of Business: Phone: <br /> Contact Person: <br /> ph%'sical ?Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN / <br /> rf�ffl/ <br /> SITE DISPOSITION 712 <br /> EH 22 013 (Rev, 03/20/93) <br />