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--,SAN JOAQUIN COUNIY <br /> NO TICATION OF IriAZ A RDOUS W r. DISCI TARGE <br /> 4 ALTH & SAT--=.TY CCDE zao.7 D <br /> i <br /> HS-EH LOG <br /> A. EMERG'r NCY LEVEL: I U III <br /> (Circe One) <br /> B. <br /> SOURCE ZF INFORMATION � Phone: Zn,� % <br /> Naive: A-- <br /> Company: <br /> Address: OF.c Phone: '- <br /> Designated Employer Name: c�— <br /> ReDotting Agency Name: <br /> Ad(iress: <br /> I� <br /> C. LOCATION AND DATE OF DISCHARGE. <br /> Locarion: , <br /> M ' <br /> County) Circle One <br /> i€ (Best Physical Description) <br /> Dare of Discharge• <br /> Dare Noo.aed: <br /> D. RESPONSIBLE. PERSONYBUSINESS <br /> Name or Bus7ness' // <br /> Coarac: P`rson:- Telephone: <br /> Physical Address: <br /> M `ailing Address- C' <br /> II <br /> E. DESC:R-r?TIQN <br /> Ty, e of Discharge: 14 R <br /> Vol=e: �1j'L��� Art_ <br /> C..1�-C3s: ' <br /> C:'cur zances: <br /> F. ACTION T_AN <br /> C E - Y <br /> ape <br /> Si i c DISPOSi TON <br /> � L 0 P L � <br /> zklki�� <br /> 49 <br /> i <br /> E"--:. 7-2 01 3 (Rev.=/91) <br /> 4 <br />