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0 SAN JOAQUIN COUNTY 6 <br />0 TIFICATION OF HAZARDOUS WASTE DISCHARGE <br />HEALTH & SAFETY CODE 25180.7 <br />A. EMERGENCY LEVEL: I II III PHS -EH LOG # <br />(Circle One) <br />B. SOURCE OF INFORMATION <br />C. <br />Name: Phone: �) <br />Company: <br />Address: <br />Designated Employee Name: Phone: (_) <br />Reporting Agency Name: <br />Address: <br />LOCATION AND DATE OF DISCHARGE <br />Location: 2121 7-vcic�rL,rr�awt Qr\� / <br />(Best Physical Description) <br />Date of Discharge:st-z-ZINrl <br />(CityCounty ircle One <br />Date Notified: Time: q•. ==Q cern <br />D. RESPONSIBLE PERSON/BUSINESS <br />Name of Business: <br />Contact Person: Telephone: St Sc:, -7_ 2g5;,s <br />Physical Address: <br />Mailing Address: S tJ U E L, CA �e <br />E <br />F <br />DESCRIPTION <br />Type of Discharge: be.% 4« L; me --97� CtAW]JAK V/l C -C <br />Volume: a4)6•4 <br />Chemicals: <br />Circumstances: 'Q-�'C Lo �, <br />EH 22 013 (Rev.4/91) <br />