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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL I, II III C 0 u �fPHS-EH LOG # 42 <br /> iiicle One) <br /> B. SOURCE O, INFpR�//jATION <br /> Name: 10g/ ! e{ n&L Phone: C! B/6 zz Z <br /> Company fniCk -�- ZP"e2 <br /> Address: a ice! 9 <br /> Designated Employee Name: Phone: (�Oqj 3 <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATOF DISC GE <br /> Location: 1&Z/ YbOfS�lcle / CK n <br /> (Best Physical Description) (�Ci r County) Circle One <br /> Date of Discharge: Nh <br /> Date Notified: 2 IB Z Time: P00 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business '5701 � Uil41'edl447� A97�-, f <br /> Contact Person: /...eabn&). Telephone: <br /> Physical Address: 1 R32 C/ P1 11,,L '227 c401 95001 <br /> Mailing Address: S4ag-� <br /> E. DESCRIPTION <br /> Type of Discharge: lea :Cn2m 05/ <br /> Volume: Um g m cn <br /> Chemicals: <br /> circumstances: fl e v " rid z4L;0 se-<Z 1 llh&u�� _ <br /> F. ACTION TAKENf e7 <br /> SITE DISPOSITI N <br /> Y f �. <br /> EH 22 013 (Rev.4/91) <br />