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SAN JOAQUI NCOUNTY E DISCHARGE <br /> NOTIFICATION OF HAZARD <br /> HEALTH & SAFETY CODE 25180.7 <br /> PHS-EH LOG <br /> A. EMERGENCY LEVE('(circll le One)III <br /> c I <br /> B. SOURCE OF INFORMATION / Gv� <br /> �s Phone: (223, <br /> Name: <br /> > - i <br /> Company: Y <br /> J 7--i Phone: L �---- <br /> Address:� //� SP <• cs <br /> Designated Employee NameAgency g Y Name: :_ �` , f, <br /> - - <br /> Address: <br /> C LOCATION AND DATE OF DISCHARGE / <br /> r CountC' cle One <br /> oy <br /> Location: don) i• .P s <br /> (Best Physical DescriP j7 <br /> Date of Discharge: ' Time: <br /> Date Notified: <br /> D. RESPONSIBLE PERSON/BUSINESS a Sb 7s <br /> Name of Business: S o% Telephone: <br /> Contact Person <br /> ✓ i, iv- G3 lam ' <br /> Physical Address: / <br /> Mailing Address' <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> volume: i ,� u <br /> Chemicals: r "` ~ / c , c' <br /> i rPr' k"Fs <br /> Circumstances* _ <br /> F. ACTION TAKE® <br /> SITE DISPOSITION - � <br /> ' ' <br /> / ✓ is <br /> EH 22 013 (Rev.4/91) <br />