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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III <br /> PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Sr Phone: C2L-,j) gi f-7-X00,1 <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: (� <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE F DISCHARGE <br /> Location: q- ' • A n-C�, / 7 4 <br /> (Best Physical Description) J or County) Circle One <br /> Date of Discharge: <br /> Date Notified: /2-//v1q7 Time: 3. � <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: fr 5, ^ <br /> Contact Person: Telephone: Q:g�, q7 <br /> Physical Address: _ -- -- _ <br /> Mailing Address: <( 7 �-t S�-a cam_ f A- 4 <br /> E. DESCRIPTION <br /> Type of Discharge: &-a&— zCLI-ec <br /> Volume: b -- a <br /> Chemicals: Q c c <br /> Circumstances: ac,,,-k _ vw <br /> F. ACTION TAKEN 1 G D•S. c <br /> 72701 dq <br /> d <br /> SITE STATUSr-�-�X <br /> EH 22 013 (Rev.4/91) <br />