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• SAN JOAQUIN COUNTY • <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHA4R E Copy <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG# <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Name: 12 Phone: 04q) 831 ­4P767 <br /> Company: > <br /> Address: i <br /> Designated Employee Name: 4Zt,% phone: <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location:,2,1o6o <br /> (Best Physical Description) CC/(Ci County) Circle one <br /> Date of Discharge. '9 — 0 7 <br /> Date Notified: �ti' � — ly / Time: 16,'I)o <br /> D. RESPONSIBLE PERSON/BUSMESS <br /> Name of Business: (_ /' A) -'r GL G R h <br /> Contact Person: Phone: <br /> Phvsical Address: 3- <br /> Mailing Address: ('0-C <br /> Cf} <br /> E. DESCRIPTION <br /> Type of Discharge: P o wi <br /> Volume: i <br /> Chemicals: <br /> Circumstance : <br /> t <br /> F. ACTION TAKEN <br /> J ' <br /> SITE DISPOSITION Ie <br /> � a <br /> 7 <br /> C/o � <br /> EH 22 013 (Rev. 08/20/98) <br />