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SAN JOAQUIN COUNTY <br /> NOTIFICATION <br /> OF& SOAFETYCUS ODE�80.I CHARGE C O nM <br /> A. EMERGENCY LEVEL: I II [II PHS-EH LOG # 1 b G Y(1 <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: �) <br /> Company: Arc.- e--) <br /> Address: <br /> Designated Employee Name: Phone: �) <br /> Reporting Agency Name: <br /> Address:_ O c{ <br /> C. LOCATION AND DATE OF D[SC G <br /> Location: 18970 <br /> (Best Physical Description) (City oz un oircle One <br /> Date of Discharge: <br /> Date Notified: Time: 12,&o aw <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: AQC o -F-QC <br /> Contact Person: X11 77-- ra o V r.. Telephone: L_) <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: d SMS /I Lam,,L <br /> Volume: Loy A aim\ <br /> Chemicals: <br /> Circumstances: L=- L,\ V-1. �I; .tcP2 <br /> F. ACTION TAKEN .la S (`n /1.0,91 ;SjQfnKeR. <br /> \,J( s ��— <br /> SITE DISPOSITIO 1N1 <br /> S�d � � Llw1C� 4ni,c-�- �'�lnl�i�n-�-ad 57A7� <br /> EH 22 013 (Rev.4/91) <br />