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�✓ SAWN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFE T`; CODE 25180.7 <br /> A. EMERGENCY LEVEL: I IT III FHS-EH LOG <br /> B. SOURCE OF INFORMATION <br /> Phone: <br /> Name: <br /> Company: G/-�/ Di'>�: C- =�y�Z�C� S�'0•��' <br /> Address: �� -�v �vo�,� /2aai <br /> Designated Employee Name: /ti' /' -S,✓� ���� Phone: 2�i <br /> Reporting Agency Name:,�ftM <br /> C. LOCATION AND �5 OF CI-t � <br /> � /OVA � L 1 S�77G <br /> Location: <br /> (Best Physical Description) (City or County) Circle One <br /> Date of Discharge: LAi <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS f <br /> Name of of Business: C A r - h 5 <br /> Contact Person: L r 2 6CA L Telephone: <br /> Physical Address: P'-,Q^/ <br /> Mailing Address: v rn <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: a ° <br /> Circumstances: <br /> �t TykS S(�to .•e�,l �� a <br /> F. ACTION TAKENe re- <br /> arc <br /> u <br /> SITE DISPOSITION �L <br /> /1 1 le JA �L��rV'►11 V��J y. �e I/�LL�/� �� i'�"T� �x !� '�_ <br /> t) r—' /►/V'r'.r a i .A77 n <br /> EH 22 013 (Rev.4/91) <br />