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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL. I If III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: (_) <br /> Company: <br /> Address 14-OT,- <br /> Designated Employee Name: Phone: (� <br /> Reporting Agency Name: <br /> Address: L1 U-�kjof,:a 4-v-jCA 9 52n-;, <br /> C. LOCATION AND DATE OF DISCHARGE ' <br /> Location: / <br /> (Best Physical D ai tion) Ci or County) Circle One <br /> Date of Discharge' a q <br /> Date Notified: _f es Time: l o t oo a w� <br /> D. RESPONSIBLE PERSON(BUSINESS� <br /> Name of Business: <br /> Contact Person: Telephone: ( P.1) f3( - 1 X 56 <br /> Physical Address: ?ACQ hvL4 'A,- <br /> Mailing Address: M <br /> E. DESCRIPTION <br /> Type of Discharge: n ' s <br /> Volume: QMICNow� <br /> Chemicals: Lia sok <br /> Circumstances:gni Qz ILui� ;7!rj <br /> F. ACTION TAKEN �11rJu .lo c Tt�Mr�ut11 <br /> SITE STATUS �ArJ� �F M�J�c� 2 -�2:4E GitS 5s YLEnI_�_—r l <br /> 1h' S 1 VIZ 1`P CG$54NL '� �iAt'l�lE �YYEA)-� L1 COM:A1L�huV <br /> EH 22 013 (Rev.4/91) <br />