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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> (C,(0Py <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III <br /> PHS-EH LOG # _a <br /> (Circle One) <br /> B. SOURCE F INFORM TION phone: C21n q6 <br /> Name: <br /> Company: � <br /> Address: 2-2-7- <br /> Designated Employee Name: hone: C___) <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE 0,FDISCHA,�LGFj,,. <br /> Location: 73Q E-- Q' �t - /," <br /> (Best Physical Descri ti ) _ty_or County) Circle One <br /> Date of Discharge: ze / ' <br /> Date Notified: �Z r) f Time: <br /> r , <br /> D. RESPONSIBLE PERSON/BUSINE S <br /> Name of Business: K <br /> Contact Person: 1 J r Telephone: ( ) <br /> Physical Address: 3 L- <br /> Mailing Address: •U . � x� ~° <br /> E. DESCRIPTION 1 <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Circumstan__s <br /> F. ACTION TAKEN '` <br /> SITE STATUS ,,O <br /> A. <br /> EH 22 013 (Rev.4/91) <br />