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SAN JOAQLLr COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCH. IL E COPY <br /> HEALTH & SAFETY CODE 2-180.1 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG T 01 - 0,04 <br /> (Circle one) <br /> B. SOURCE OF INFORMATION <br /> Name: e? Phone: <br /> Company: <br /> Address: GU L- <br /> Designated Employee Name: c Phone:(-zo f) <br /> Reporting Agency Name: � <br /> Address: <br /> C. LOCATION A1NtD DATE OF DISCI -VRGE <br /> Location: 13 n 's , of �� <br /> (Best Ph%sicai Description) T (ClR or Count) Circle one <br /> Date of Discharge: / _ / 7 - [> / <br /> Date Notified: - 1 :7 — 6 1 Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: 6 7 # <br /> Contact Person: C Phone:(7l7Z� <br /> Physical _address: <br /> MailinJ Address: 2 � � �S <br /> E. DESCRIPTION <br /> Type of Discharge: <br /> Volume: <br /> Chemicals: <br /> Fill <br /> Circumstances: J nag <br /> F. ACTION T. <br /> LL � <br /> D <br /> SITE DISPOSITION . c� <br /> t <br /> EH 22 0 L 3 Rev. 08120/98) <br />