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1 " <br /> SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: [ } <br /> Company:, <br /> Address: <br /> Designated Employee Name: Phone: U <br /> Reporting Agency Name: <br /> Address: La.� Qgrz ze= <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: / <br /> (Best Physical D cription) r County) Circle One <br /> Date of Discharge: <br /> Date Notified: � I�� ... Time: 11-w> <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 1A� s <br /> Contact Person: Telephone: ) <br /> Physical Address: <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: 2 - <br /> Chemicals: - i <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE DISPOSITION f <br /> EH 22 013 (Rev-4/91) <br />