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SAN JOAQUIN COUNTY i <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL011 III <br /> PHS-EH LOG # <br /> (Circle One) <br /> B, SOURCE OF INFORMATION <br /> Name:_ Z� S7Cg,::,p <br /> Company: <br /> � -4 6 u l� Phone: ( <br /> Address:_[O <br /> Designated Employee Name:_ -A <br /> Reporting Agency Name: Phone: <br /> Address:_ G z/'5 <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: 1,26 <br /> (Best Physical Description) <br /> Date of Discharge: — �(CYty or County) Circle One <br /> �c%ti�r�l <br /> Date Notified: t//7/� Tune: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: <br /> Contact Person: Telephone: (_) <br /> Physical Address: Z 3 �-7 <br /> -_�i sitiio?T=c'o �4C�9 rPo cr9— <br /> Mailing Address: ��s 7 s �/ ��6 iii j � 5—pl;Zo > <br /> E. DESCRIPTION <br /> Type of Discharge: � Qi -� <br /> Volume: <br /> Chemicals saG <br /> Circumstances: -vic�ri crG vc-ice > , <br /> F. ACTI^ON TAKEN ✓n <br /> o / <br /> SITE DISPOSITION <br /> EH 22 013 (Rev.4/91) <br />