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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 FYOG #_ / 1 <br /> Circle One ` <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: <br /> Company:_ Ag cco 14M/O/Y) <br /> Address: <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address:____?O v-=- 6 g-, <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: n,� C ,yj,4 / <br /> (Best Physical Description) Ci or County) Circle One <br /> Date of Discharge: (r-� - 2R _ q5- <br /> Date Notified: ID - �/ �� Time: ,Z:�S <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: (_) <br /> Physical Address: <br /> Mailing Address: s,4 wi <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstance <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.4/91) <br />