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t <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: ] I III PHS-EH LOG # <br /> 5 <br /> ( irL1cle One) <br /> B. SOURCE OF INFORMATION <br /> Name: 065 Phone: &2) <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone: (� <br /> Reporting Agency Name: <br /> Address: <br /> C. LOCATION AND DATE OF D SCHARGE <br /> Location: <br /> (Best Physical De caption (City _ Coun Circle One <br /> Date of Discharge; / /� 2� /.'00 P <br /> Date Notified: / / Time: 2-= 3 O AM . <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: U,,Pu d'v-, RL-e- kL R,%J -,r4 <br /> Contact Person: D6Telephone: /6 <br /> Physical Address: Rm. q6 S S.r. io 5- <br /> Mailing <br /> Mailing Address: 5 <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: 6'00 z f 5'00t <br /> Chemicals: w 1 <br /> Circumstances: ,:. ccwi,c cz Q. SoU <br /> F. ACTION TAKEN <br /> a. � <br /> SITE STATUS L � 7,✓z.�-(� _al-9 134Ai� <br /> EH 22 013 (Rev-4/91) <br />