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~ SAN JOAQUIN COUNTY <br /> NOTIFICATION OF ODISCHARGE <br /> CHARGEHEALTH & SAFETY CODEgp. f <br /> CCO) <br /> A. EMERGENCY LEVEL: III III <br /> P <br /> (Circle One) HS-EH LOG # <br /> B. SOURCE OF INFORMATION \ <br /> Name: <br /> Company: Phone: (_ <br /> Address: <br /> Designated Employee Name: u ri4a <br /> ­phone. <br /> v. <br /> 8 �Reporting Agency Name:!o : 1 <br /> Address: 3oq >= UJe-k,y- G4 <br /> C. Loi nO �DS�Anab N AND E OF I�13GrJSf (�T4 Ate; r19-19d o3 I <br /> (Best Physical Description) (City o ounry) ' cle One <br /> Date of Discharge: (dvNJ�,kzwv) <br /> Date Notified: I2L -Y� Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: v 'DM( <br /> Contact Person: Ja D' Neill 0 Telephone: 10 7Ri -33(0 <br /> Physical Address: a z p lea p l ( CJ4 S 2 <br /> Mailing Address: ;&ykQ, as a <br /> E. DESCRIPTION <br /> Type of Discharge: Ut <br /> \__ I L (G <br /> Volume: � <br /> Chemicals: 04,So <br /> Circumstances: i &0 / U a) y _ <br /> Y> <br /> (,DV( '�tt5 -hFD uhearbr�G(c 4Q <br /> �I liti cede Face �f l� �'° pe . <br /> F. ACTION TAKEN <br /> 11i2flicr I Wi <br /> SITE TATUS Sr QC N� e <k �v� ( Slc Lf ( Vel <br /> Q Val 6f v tk <br /> 'e- u k (S c <br /> EH 22 013 (Rev.4/91) 05( <br />