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SAN JOAQUIN COUNTY • <br />NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVEL:(L I III PHS -EH LOG # 93 y 3 <br />(Circle One) <br />B. SOURCE OF INFORMATION <br />Name: �o�? ��� Phone: (E�n) 7 <br />Company: R <br />Address: 7 1 D /ate T G G o 9 <br />Designated Employee Name: Phone: <br />Reporting Agency Nam - <br />Address: le1�5 S 0� io QQ vS ST. Sib�K-ia 9Szv / <br />C. LOCATION AND DATE OF DISCHARGE <br />Location: 5�7 Z9 w . zZ ALAS u� <br />(Best Physical Description) (City or,ounty Circle One <br />Date of Discharge: z2 -v <br />Date Notified: Time: <br />0 <br />E. <br />F <br />RESPONSIBLE pRRC()N/RtiCTNFCC <br />Name of Busines <br />Contact Person: <br />Physical Address <br />Mailing Address; <br />nFcra )TTrW <br />EH 22 013 (Rev.4/91) <br />