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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL::II IIIC <br /> ©Pr S-EH LOG # <br /> ( rcle One) <br /> B. SOURCE I F RMATION <br /> Name: Phone: lam 9) - 9 2 <br /> Company <br /> Address: <br /> Designated Employee Name: Phone: 0)-s4:52- <br /> Reporting <br /> - 52Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND_I�ATE OF DISCHARGE <br /> Location: <br /> (Best Phyiical Description) tty r(dounty) Circle One <br /> Date of Discharge: (2-75-92 <br /> Date Notified: Time: Pj : SAM <br /> D. RESPONSIBLE PER SON/BUSINES <br /> Name of Business <br /> Contact Person: Telephone: (20%) <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: ti u (p ' <br /> Chemicals: <br /> Circumstances: <br /> F. ACTION TAKEN <br /> 11W b Paha6oA r ►�v <br /> �D. <br /> SITE DISPOSITION p & (1/z/D ✓k% / oih u 7r9 40ZIL iP Z <br /> EH 22 013 (Rev.4/91) <br />