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• <br />VSAN JOAQUIN COUNTY <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVEL:0 II III PHS -EH LOG # �� l <br />(Circle One) <br />B. SOURCE OF INFORMATION -/� <br />Name: LL PE Re- [CX 5 Phone: <br />Company: S i -i c Cent. <br />Address: <br />Designated Employee Name: Lo <br />Reporting Agency Name: <br />Address: <br />C. LOCATION AND DATE OF DISCHARGE <br />(Best Physical Description) <br />Date of Discharge: /cnhQ a2 rs2 <br />Date Notified: / 0, - / '7 - 9 <br />D. RESPONSIBLE PERSON/BUSINESS <br />Name of Business: <br />• Contact Person: I c,_�_ <br />Physical Address: LVE RD I I i `Y! <br />Mailing Address: <br />E. DESCRIPTION <br />Type of Dische <br />Volume: Gc2 <br />Chemicals: <br />F <br />• <br />TA <br />/ S/D C- f�2 <br />(City o C�o ) ircle One <br />Time: `'j : 0-0 <br />c�,v <br />Telephone: CEM) 75,�—,Rl�777-,3Ct <br />-- ./. r� r_ I <br />EH 22 013 (Rev -4/91) <br />