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j • SAN JOAQUIN COUNTY • <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: 111 III PHS-EH LOG # <br /> ( cle One) <br /> B. SOURCE OF INFORMA <br /> Name: 1 Phone: <br /> Company: <br /> Address: <br /> Designated Employee Nam : Phone: L� <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF DISCHAR E <br /> Location: 24103 W- M O,r (n <br /> (Best Physical Description) Ci r County) Circle One <br /> Date of Discharge: u) n <br /> Date Notified: _( � �2-�1�, Time: '00 <br /> D. RESPONSIBLE PERSON USIN SS <br /> Name of Business: CKf3Y- E 1 # 10 <br /> Contact Person: Telephone: L) QqO-Pj z72 <br /> Physical Address: ' LAZE &I , ef I DOYD-40 � ,alm ak4rn 95 LOL <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: 1e k �n1YV1 �l <br /> Volume: U/r <br /> Chemicals: <br /> Circumstances: 26 �i Il2� <br /> F. ACTION TAKEN�a/0j —j2/2I< Q4716ya_.Q . <br /> SITE DSP SITION " rilha* 1n <br /> Mg- I g J <br /> 11 44X r ar <br /> cr Uk cB <br /> EH 22 013 (Rev.4/91) <br />