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SAN JOAQUIN COUNTY 00 poly <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A <br /> EMERGENCY LEVE011 I II III PHS-EH LOG # <br /> F <br /> role One) <br /> B. SOURCE OF INFORMATION <br /> Name: Phone: �) <br /> Company: 1 <br /> Address: <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: ^' gr al^ � <br /> Address: 44S- <br /> C. <br /> .S'C. LOCATION.AND DATE OF DISCHARGE <br /> Location: Z �- / -- <br /> (Best Physical Description) qty r County) Circle One <br /> Date of Discharge: _ Ui&U - <br /> I. <br /> Date Notified: Time: �3 <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: --� <br /> Contact Person: Telephone: ( ) <br /> Physical Address: Z, - <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: I <br /> Volume: <br /> Chemicals: Z7 <br /> Circumstances: 'a jr-'r � k e 1sm�l�,�, � ► <br /> r <br /> F. ACTION TAKEN <br /> SITE STATUS ,_ <br /> EH 22 013 (Rev.4/91) <br />