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SAN JOAQUIN COUNTY NOTIFICATION OF HAZARDOUS WASTE DISCHARGEC(DPY <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I0I III PHS-EH LOG # " <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: -7 --«c ye- 1 ,1 Phone: (� <br /> Company: A-r c 0 <br /> Address: <br /> Designated Employee Name: ex.""0. Phone: zoo y62-°33`/ <br /> Reporting Agency Name: Sr 6o . E �b <br /> Address: `1`'l S .0 Sa., J o4 7 S��(L�� C{ S 5L,1/ <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: q-co C. N<c 4\c <br /> (Best Physical Description) Cityo County) Circle One <br /> Date of Discharge: .. vA0`J^ <br /> Date Notified: ;S- z-,� y Time: L�',DO P <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: 3+a %40'r zoos <br /> Physical Address: <br /> Mailing Address: C� <br /> E. DESCRIPTION <br /> Type of Discharge: 4w �� z�e.Q e e4 se r•o M V T P� �� <br /> Volume: <br /> Chemicals: sa I _ <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE STATUS -j,-' <br /> v.� &.45 Z!14 hic.-Iv� 1rcJ <br /> EH 22 013 (Rev.4/91) <br />