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SAN JOAQUIN COUNTY U <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGE <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: I II III PHS-EH LOG # 9�,�_142 <br /> (Circle One) <br /> B. SOURCE ZINFORMATION <br /> Name: coAjr ✓ Phone: <br /> Company: <br /> Address: <br /> Designated Employee Name: Phone:4k2),V,6 e-3 y& <br /> Reporting Agency Name: <br /> Address: <br />' C. LOCATION AND DATE OF DISCHARGE <br /> Location: f W CLkIle <br /> (Best Physical Description) (Cit or County) Circle One <br /> Date of Discharge: <br /> Date Notified: — 1 7-- Time: ` <br />' D. RESPONSIBLE PERSON/BUS ESS <br /> Name of Business: . <br /> Contact Person: .-:±' c E Telephone: <br /> Physical Address: J CJ <br /> Mailing Address: <br /> E. DESCRIPTION <br /> Type of Discharge: S <br />' Volume: " <br /> Chemicals: <br /> Circumstances: <br /> 1 ' <br />' F. ACTION TAKEN <br />' SITE DISPOSITION <br /> G <br />' r <br /> c <br /> EH 22 013 (Rev.4/91) <br />