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SAN JOAQUIN COUNTY <br /> NOTIFICATION OF HAZARDOUS WASTE DISCHARGECOO L MCD <br /> HEALTH & SAFETY CODE 25180.7 <br /> A. EMERGENCY LEVEL: II III PHS-EH LOG # <br /> (Circle One) <br /> B. SOURCE OF INFORMATION <br /> Name: ��� ��� / Phone: Ls �!(h "2 4 � <br /> Company: ��;,t a '!�,: .C�:G� �S•'� <br /> Address: C N , S <br /> Designated Employee Name: Phone: <br /> Reporting Agency Name: S cz-- ct 4, <br /> Address: T <br /> C. LOCATION AND DATE OF DISCHARGE <br /> Location: /i C�1 �, /26 c';, rte` Sal` <br /> (Best Physical Description) Ci r County) Circle One <br /> Date of Discharge: <br /> Date Notified: Time: <br /> D. RESPONSIBLE PERSON/BUSINESS <br /> Name of Business: Au <br /> Contact Person: _ 1 - Telephone: (Z.�2D U <br /> Physical Address: iii+ 5 E7 <br /> Mailing Address: <br /> E. DESCRIPTION j <br /> Type of Discharge: <br /> Volume: S <br /> Chemicals: t S = <br /> Circumstances: <br /> F. ACTION TAKEN <br /> SITE DISPOSITION <br /> ,/l <br /> EH 22 013 (Rev.4/91) <br />